
Class JES/^SL. 
Book ^ ^<T 
CopghtN 



COPYRIGHT DEPOSIT. 



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SPECIFIC DIAGNOSIS 



STUDY or DISEAS 



WITH SPECIAL REFERENCE TO THE 



ADMINISTRATION" OF REMEDIES. 



JOHN M. SCUDDER, M. D., 

Professor of the Principles and Practice of Medicine in the Eclectic Medic*. 1 . 

Institute; author of "The Practice of Medicine," " The Practice 

of Medicine in Diseases of Children," "The Principles 

of Medicine," " Diseases of Women," "Specific 

Medication and Specific Medicines," etc. 



TENTH EDITION. 




CINCINNATI, 0.: 
THE SCUDDER BEG&| CO. ' ' • 
1903. 



THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

MAY 29 1903 

Copyright Entry 

CLASS ^ XXc. N< 

COPY B. 



Xc. Nc. j 



n 



v/.*6 



Entered according to Act of Congress, in the year 1874, 

BY JOHN M. SCUDDER, 

In the office of the Librarian of Congress. 



Copyright, 1903, by 
THE SCUDDER BROS. CO. 






PREFACE 



In presenting this volume to the profession, as a com- 
panion to " Specific Medication and Specific Medicines," 
my object has been to make a study of the prominent ex- 
pressions of disease, with reference to the administration of 
remedies. However learned we may be in pathology, and 
associate branches of medical study, unless we can make our 
knowledge point to means for the relief of suffering, the 
arrest of disease, and restoration to health, it will be of but 
little use. 

We believe that the expressions of disease are uniform, and 
always have the same meaning, and that the action of reme- 
dies is something definite aud uniform — "that like causes 
always produce like effects." If we properly study our cases, 
so as to determine a definite condition of disease, and know 
the direct action of remedies in such conditions, we will 
have a certain and rational practice of medicine. 



IT PREFACE. 

I concede that the study is difficult, but it is difficult 
principally 1 ecause it is new, and sufficient observations have 
not been made. Physicians have so long practiced by rote, 
and taken it for granted that there was no " certainty in raedi 
cine," that we have not the material we would wish for spe 
cine diagnosis. But attention is being directed to it, and the 
time is coming in which the field will be full of observers. 

No apology is made for the shortcomings of this little book, 
though I hope that in the main, experiment will prove the 
correctness of its statements. It would be singular if there 
were not some errors, and some things to be corrected by 
further experiment and study. It does not profess to be a 
complete treatise, or to give all the information that might 
be thought desirable. But it is a study of disease, which 
may be continued by other books and at the bed-side of the 
sick. - 

If it serves the purpose ot stimulating investigation and 
thought, pointing the road to a better system of medicine, I 
will be fully compensated for the labor. 

Cincinnati, Nov. 15, 1874. 



ON THB 



STUDY OF DIAGNOSIS. 



YT/'E wish to make a new study of Diagnosis — one 
that will show us the relation between symptoms 
of disease and the curative action of drugs. Evi- 
dently this is what we need to give us a rational prac- 
tice of medicine — very certainly it must be the founda- 
tion of specific medication. 

It is yet the opinion, that " diagnosis "has reference 
to the classification of disease according to the received 
nosology; that it means naming the affection "bilious 
fever," " typhoid fever," " pneumonia," "nephritis," etc. 
And so it does with the genus doctor, at large, and their 
souls travail in diagnosis until a suitable name is deliv- 
ered. And then they consult their memories and books 
for recipes to throw at this name, which to them seems 
almost an entity. 

It looks absurd when thus plainly stated, yet it is 
true to a far greater extent than the majority suppose. 
If we examine the literature of the profession, we find 
that writers on the "Practice of Medicine" labor to 

(9) 



10 STUDY OP DIAGNOSIS. 

make diagnosis in this way, and so arrange the symp- 
toms of disease that their readers may be enabled to 
follow in their lead. The student would certainly think, 
from this teaching, that getting a name for a disease, 
was the first and principal object in medical practice. 
Not only does this seem the principal, but the only end 
of medical study, and men pride themselves on their 
skill in naming diseases — calling it diagnosis. 

What can be more natural than that medicines should 
be prescribed at names, when so much trouble is taken 
to affix them ? And so we find that treatises on thera- 
peutics are efforts to associate drugs with names of dis- 
ease, with a — "this has been used with advantage" — 
" this has been employed in," etc., etc. The trouble is 
that almost every remedy in the materia medica has 
been prescribed at the more common diseases — pneu- 
monia, for instance — and the student has difficulty, not 
from the paucity of his means, but from their abun- 
dance. 

Some go a little further than this. They want a 
name for their disease, it is true, but they also make 
their diagnosis extend far enough to guide their thera 
peutics. Thus they determine a condition of the stom- 
ach that indicates an emetic, constipated bowels a ca- 
thartic, dry skin a diaphoretic, scanty urine a diuretic, 
periodicity Quinine, sleeplessness or pain an opiate, 
heat and dry skin baths, etc, Add to this counter-irri- 
tation for the relief of local disease, and we have the 
ordinary round of treatment. 

This kind of diagnosis is well enough — is very much 
better than that which simply names the disease — but 
it also is very crude at times. For we find at times that 
there are very much better means to relieve the stom- 



STUDY OF DIAGNOSIS. 1 1 

ach than an emetic; and that in some, where seemingly 
indicated, it would do more harm than good. That 
constipation is not an indication for cathartics, and that 
this class of remedies are so used as to do a vast amount 
of harm. That impaired secretion from the skin does 
not mean diaphoretics ; for when most indicated they 
will frequently not cause secretion ; and that other 
means, not directed to the skin, will cause it. That 
scanty urine does not mean diuretics, for they will fre- 
quently fail to influence the kidneys when they seem to 
be indicated most, and will sometimes still further ar- 
rest secretion. Periodicity does not always mean Qui- 
nine, for Quinine fails nine times where it succeeds 
once, sometimes intensifying disease, at others produ- 
cing a disease peculiar to itself — quinism — worse by far 
than the disease for which it is given. And sleepless- 
ness does not mean Opium, for it fails frequently, and, 
as generally used, does far more harm than good. 

It is still worse when the physician thinks he sees 
the need of cathartics, diuretics, diaphoretics, tonics, 
Quinine, nervines, etc., and gives them all at once, or in 
a miscellaneous hodge-podge. The common result is to 
intensify the disease, derange the stomach, and impair 
the vegetative nervous system. The remedies are fre- 
quently given so that the action of one opposes that of 
another, as for instance a cathartic with a diaphoretic, 
or at such times that they can not possibly do what they 
are intended for. 

How, then, shall we study diagnosis? Is there any 
better method than that usually pursued ? 

I believe there is a right way to study diagnosis — one 
that will prove satisfactory to patient and physician — 
will name the disease for the one, and determine a ra- 



12 STUDY OF DIAGNOSIS. 

tional therapeutics for the other. Such a way I endeav- 
ored to point out in my Principles of Medicine, to which 
my readers are referred for my opinions in extenso. 

Man has but one body, and though it may be divided 
into parts, each has the same life, is supplied from the 
same blood, governed by the same nerves, and has the 
same nutrition and waste. Only in so far as drugs act 
on special parts or organs, need we study disease of 
these independent of the organism at large. 

Man has but one life, and it is the same for all parts. 
The normal manifestations of this life we call health ; 
the abnormal manifestations of it disease. If we can 
always think of disease as a method of life, in a living 
body, we will have gotten rid of an old error, and have 
made the first step toward a correct diagnosis, and a 
rational therapeutics. 

Disease, then, is not an entity — something to be for- 
cibly expelled from a living body — but is actually a 
method of life. It can not be purged from the bowels, 
vomited from the stomach, strained from skin and kid- 
neys, or exorcised by counter-irritation. Such means 
may do good, as when they remove an offending sub- 
stance, or when they establish a function that is defi- 
cient, but they should have a rational use. 

The life of disease is not as good as the life of health, 
neither in the whole nor in any individual part. It is 
always exhaustive, impairing the life now, and the life 
to come by renewal of tissue. It makes no difference 
what may be the seeming condition of the body or a 
part in disease, the real condition is, an impairment of 
life. We study disease, therefore, as a method of living ; 
and we treat the diseased body as a living body, which 



STUDY OF DIAGNOSIS. 13 

has been placed in such position that its life has been 
enfeebled or deranged. 

We next want to understand clearly the structure and 
uses of the various parts of this one body, We want to 
know clearly the conditions necessary to healthy life, 
and how their change works that we call disease. If 
we can understand clearly the relation of a condition 
or function to healthy life, we are in a position to learn 
how the change in condition or function produces dis- 
ease, and a correct therapeutics is at once suggested. 

Examining the human body, we find certain condi- 
tions and functions underlie others, and seem to he first 
elements in the sum of life. Of these I may name tem- 
perature, circulation, innervation, nutrition and waste, 
and the blood. We always study these first, and we 
want to know the exact character of the wrong, in one 
or all, and how that wrong may be corrected. 

G-oing one step farther, we want to know the relation 
of these conditions and functions to one another. There 
is a general relation in health ; possibly they are of equal 
importance in the problem of life. But in disease one or 
other may stand first, and serve as a basis for wrong of 
life in many directions. Thus a disease involving every 
function of life, may arise in a wrong of the temper- 
alure and circulation of the blood. There is a want of 
appetite that tonics will not reach ; a wrong of secre- 
tion that can not be righted with cathartics, diaphoretics 
and diuretics ; a wrong of innervation that can not be 
reached with narcotics and nervines. Direct remedies 
that restore normal temperature and circulation, control 
the entire process of disease ; like a card-house, the re- 
moval of a first card is sufficient for the overthrow of 
the entire structure. 



14 STUDY OF DIAGNOSIS. 

It is not so easy, always, to determine which wrong 
is thus first, yet with care it may be determined — and 
this is an essential in good diagnosis. A disease pre- 
senting similar symptoms — the same symptoms to an 
ordinary observer — may rest equally upon a first lesion 
of the circulation, innervation, nutrition and waste, 
blood-making, or the conditions of the blood. We want 
to know which stands first, and then rectifying the firsf 
wrong the treatment is easy and successful. 

Disease has certain expressions, which we call symp 
toms, as health has certain expressions. We find that 
the manifestations of life in health are very uniform, and 
consistent, and one can hardly mistake their meaning 
So in disease, the expression of morbid life is uniform, 
and constant, and does not vary in different individuals, 
as many have supposed. If we determine in any given 
case the expression of diseased life, we will find it the 
same in all cases. 

It has been claimed, and tacitly admitted that symp- 
toms of disease were so changeable and inconstant, that 
they could not be depended upon with any certainty. 
This was certainly true to those who made their di- 
agnosis according to the recived nosology, and then pre- 
scribed at the name. For as very diverse pathological 
conditions would be grouped under each name, the 
symptoms would of course vary, and the treatment 
would show the element of uncertainty in so marked a 
manor that idiosyncrasy would be constantly called in to 
explain the trouble. 

We propose studying the expressions or symptoms of 
disease with reference to the administration of reme- 
dies. It is a matter of interest to know the exact char- 
acter of a lesion, but it is much more important to know 



STUDY OF DIAGNOSIS. 16 

the exact relationship of drug action to disease expres- 
sion, and how the one will oppose the other, and restore 
health. If I can point out an expression of disease 
which will be almost invariably met by one drug, and 
health restored, I have made one step in a rationa. 1 
practice of medicine. 

I have no hesitation in affirming that if we have once 
determined such relationship, we have determined it 
in all diseases alike, in all persons, and for all time to 
come. If, with this symptom or group of symptoms, 
my Aconite, Nux or Podophyllin cures to-day, it will 
cure to-morrow, next year, and so long as medicine is 
practiced. If it cures Tom, it will be equally applicable 
in the same condition to his father, mother, wife, or 
mother-in-law. 

"Do you mean to say," asks the reader, " that the 
present system of nosology is useless? " Yes, so far as 
curing the sick is concerned, that is just what I mean 
to say. Not only useless, but worthless — a curse to 
physician and patient — preventing the one from learn- 
ing the healing art, and the other from getting well. 
But you may ask, "how would you make out the certifi- 
cate for the Undertaker? " That's just what we wish to 
avoid, we don't care about furnishing subjects, and 
would very much rather people should die of old age, 
and then we would write it in English — " old age." 

The first lesson in pathology we want to learn is, that 
disease is wrong life. The first lesson in diagnosis is, 
that this wrong finds a distinct and uniform expression 
in the outward manifestations of life, cognizable by our 
senses. The first lesson in therapeutics is, that ail 
remedies are uniform in their action ; the conditions be- 
ing the same, the action is always the same. We learn 



16 STUDY OF DIAGNOSIS. 

to know the healthy man — know him by exercising all 
our senses upon him. We want to know how he feels, 
how he looks, how he smells, how he tastes, and what 
kinds of sound he makes. Then we want to learn the 
diseased man in the same way, and compare him with 
our healthy standard — certain expressions of life mean- 
ing health, and certain other expressions meaning dis- 
ease. Then we study the action of drugs upon the 
tick, and when we find them exerting an influence op- 
}«osed to disease and in favor of health, we want to 
know the relation between the drug and the disease — 
between disease expression and drug action. 

I do not say that we should not study drug action in 
health — indeed I think it a very important study. You 
may, on your own person, study a wholly unknown 
drug, and determine its proximate medicinal action. 
How ? Easy enough. You will feel where it acts ; that 
points out the local action of the drug, and as a matter 
cf common sense, you would use it in disease of that 
part, and not of a part on which it had no action. You 
will feel how it acts — stimulant, depressing, altering the 
innervation, circulation, nutrition and function. If now 
you want to use it in disease, use it to do the very things 
it did in health, and not as our Homoeopathic brethren 
would say, to do the very opposite things. 

This might not seem altogether pertinent if we were 
t-tudying old diagnosis, but new diagnosis means rnedi- 
(dne, and must point out the cure for the particular case 
in hand. 



STUDY OF DIAGNOSIS. 17 

THE STUDY OF LIFE. 

The diagnosis that wo are studying lias a physiologi- 
cal basis, and we want to learn something of the kind 
of physiological knowledge necessary. Is it that which 
may be learned from Carpenter, Draper, Huxley, etc. ? 
Most decidedly it is not. The knowledge from books is 
most important, excellent in its place, but worth nothing 
here unless supplemented by a new study. 

We must study the living man, and learn to recognize 
every manifestation of this life by our senses. 

Nothing less will serve the purpose in rational med- 
icine. We want to bring our own senses to bear upon 
him, and know how he feels, tastes, smells, and how he 
looks and vvhat sounds he makes. This study of the 
living man, the most important study in medicine, is al- 
most wholly neglected. Men live a lifetime, and know 
nothing of the manifestations of life. Students become 
conversant with books, attend their lectures, pass their 
examinations, and yet have no practical knowledge of 
human life. And physicans will practice medicine a life- 
time, and yet fail, to know what healthy life is. 

How would you make a good surgeon ? There is but 
one way. Ho must exercise his senses on the human 
body, and learn to know it for himself. He studies upon 
the cadaver, and learns the relation of parts; and he 
also studies che living man, and learns to recognize 
these relations by the sense of touch. Your accom- 
plished surgeon recognizes a displacement or fracture, 
as soon as his eyes rest on the part. Let him pass his 
fingers ovor a limb in the dark, and he will tell you if 
anything is wrong, and just what the wrong is. He is 
a good surgeon, just exactly as he is an expert in this. 



18 STUDY OF DIAGNOSIS. 

l^ot a year passes but what we have one or more 
suits for malpractice against physicians of our school, 
arising out of bad bone-surgery. (They have quite as 
many in other schools.) Why these cases ? Simply be- 
cause they have not taken the trouble to learn on the 
cadaver and living body for themselves, just how it is 
made, and the relation of one part to another. Any 
man, whether he is a surgeon or not, can so train his 
senses, and know the anatomy of man, that mistakes 
would be impossible, and cases of malpractice would 
be the result of accident, or the fault of patients. 

1 say to the student, study anatomy and physiology 
on the living man. Observe him closely with your eyes, 
until you learn his varied expressions. See him walk, 
sit, lie, work, eat, breathe, talk, etc. Feel of him, and 
see how he is made, and what he feels like in different 
parts. Learn every prominence of bone in the body, 
and its relation to articulations, blood-vessels, nerves, 
organs, etc. Hear every sound he makes, and learn to 
recognize its character. And, lastly, learn to recognize 
all of the many smells of which he is the base. Learn 
him from the crown of his head to the sole of his foot, 
and analyze him with your own senses, and you will 
have the foundation for a good physician. 

I place very great stress on this method of studying 
physiology, and recommend it to the old practitioner as 
well as the medical student. !N"o knowledge in the 
memory can take its place. It must be the basis of a 
rational practice of medicine, for unless we know what 
health is, we can not know disease, and unless we knoio 
disease we will have a random and very uncertain 
therapeutics. 

I have already called attention to the necessity of 



STUDY OF DIAGNOSIS. 19 

training all our senses so that we may be able to observe 
well. These faculties are like many others, they may 
be so trained under the influence of the will, that 
after a time they work automatically, and with a rapid- 
ity that is astonishing. This is the work of time — but 
time placed where it will do the most good. All that 
one need do, to have good, active senses, is to use wha) 
he has rightly. 

There is no mistake about these things, and I will 
guarantee any physican a success that will astonish him, 
if he will put them in practice. Need I say that the 
reward is great. Outside of professional reputation, 
and the ordinary rewards of successful business, there 
are sufficient returns. A man's conscious life is in and 
through his senses, and as these are educated and en- 
larged, his life becomes larger, and his pleasures in- 
creased. Nature is a most bountiful mother, and her 
laws bring certain compensation ; and of these there is 
none truer than that " a man grows as he is rightly 
used." 

Applied Anatomy. — The ordinary study of anatomy 
is a good thing, and is the basis for a sound medical 
education. Yet I am sorry to say that the study of 
anatomy with the majority of physicians is very "■ ordi- 
nary." It is a good thing to be able to name the 
various bones, processes, muscles, and organs of the 
body, but it is very much better to know them, as a 
man knows his best friend. I may know a man's name, 
and yet know really nothing about him, physically, 
mentally, or morally. So it is in the common study of 
anatomy, the memorizing of names takes the place of 
that study which will enable one to really know the 
structure of the human body. 



20 STUDY OF DIAGNOSIS. 

A good anatomist will strongly insist on dissection a& 
an important means of learning. He well understands 
and endeavors to impress the fact that it is only by 
personal examination that one may know the various 
tissues and organs, and their relation to one another. 

The surgeon supplements this by the additional state- 
ment that the most important preparation for the use 
of the knife in surgery, is the use of the knife in dis- 
section. Not only to acquire anatomical knowledge, 
but to know the resistance of different tissues to the 
scalpel, and to train the sense of touch. 

An accomplished physician should be a good anato- 
mist — the skilled diagnostician is a good anatomist. 
No one need say he has no opportunity, for every one 
can make opportunity. A dead man is a good thing in 
this study, but any animal or part of an animal will 
serve the purpose of the man who really wishes to 
know, and there is not so very much difference between 
man and the remainder of the mammalia. The nearest 
butcher shop will furnish material in abundance — from 
eyes, to tongue, larynx, trachea, bronchial tubes and 
lungs ; the digestive canal and its associate organs ; 
kidneys, etc. : whilst a quarter of lamb or veal gives 
pretty good muscular dissection. 

The worthless curs prowling about the village or 
town, give excellent facilities for dissection or vivisec- 
tion. Chloroform the brute, and he is ready for work, 
and you may educate your touch on living tissue, as 
well as learn anatomy. 

In the olden time the study of anatomy was com- 
menced with the bones — not with pictures or plates of 
bones- This study in which bones are tangible reali- 
ties, and convey to the sense of touch and the eye their 



STUDY OP DIAGNOSIS. 21 

peculiarities is the right study. Every physician 
should he able to recognize any hone hy the sense of 
touch, and at once give it its proper position. Just as 
he should be ahle to recognize the normal from the ab- 
normal in shape, size and position. The skeleton prop- 
erly articulated is a valuable adjunct, and if it was 
thoroughly studied by the hands in a dark room, we 
would have but few cases of mal-practice in bone- 
surgery, 

But this study of anatomy from the skeleton, and by 
dissection, assisted by reading and lectures, is but pre- 
liminary to a more important study. We want to study 
anatomy upon the living man. We want to know the 
situation and the relation of various parts, so that we 
may be able to put our finger upon them at once, and 
detect the slightest variation. We want the impress 
of this living man upon our senses, so that they may 
know him intimately. What does he look like? What 
does he smell like ? What does he taste like (in so far 
as taste is applicable) ? What sounds does he make? 
And how does he feel ? 

We want to know his every expression, standing, 
sitting, lying, on his back, sides, etc. His expression 
in activity, and at rest. We study his muscles in life, 
their arrangement on the bones, and their influence in 
giving the body motion. We study the situation of 
blood-vessels in the same manner, and learn to trace 
their course by the prominences of bone, relation to 
muscles, etc., and going deeper, we study osteology 
again, as the bones are clothed in tissue. 

No man need excuse himself for want of opportu- 
nity, so long as he possesses a body of his own, and 
there are so many other bodies that might he engaged 
for the purpose. 



22 STUDY OF DIAGNOSIS. 

There are two objects in this study, both important, 
The one is to know the mechanism of life, and the 
other is to educate the senses. The importance of the 
first will not be disputed, and before we have concluded 
this study, I think the other will be conceded. 

Applied Physiology. — The knowledge of physiology 
from the books is a good thing, but it is not sufficient 
for our purpose. We not only wish to learn that Car- 
penter, Huxley, and others, have witnessed certain phe- 
nomena, and learned to know them as constant expres- 
sions of life, but we wish to know them of ourselves, 
and through our senses. 

Dr. Huxley introduces the study of physiology by 
saying — " The body of a living man performs a great 
diversity of actions, some of which arft quite obvious j 
others require more or less careful observation ; and yet 
others can be detected only by the employment of the 
most delicate appliances of science. 

" Thus, some part of the body of a living man is 
plainly always in motion; even in sleep, when the 
limbs, head and eyelids may be still, the incessant rise 
and fall of the chest continue to remind us that we are 
viewing slumber and not death. 

" More careful observation, however, is needed to de- 
tect the motion of the heart; or the pulsation of the 
arteries ; or the changes in the size of the pupil of the 
eye with varying light; or to ascertain that the air 
which is breathed out of the body is hotter and damper 
than the air which is taken in by breathing. 

"And lastly, when we try to ascertain what happens 
in the eye when that organ is adjusted to different dis- 
tances; or what in a nerve when it is excited ; or of 



STUDY OF DIAGNOSIS. '23 

what material flesh and blood are made ; or in virtue 
of what mechanism it is that a sudden pain makes oik 
start — we have to call into operation all the methods of 
inductive and deductive logic; all the resources oi 
physics and chemistry ; and all the delicacies of the art 
of experiment." 

Huxley is an admirable teacher, probably the best 
living, and we will do well to get an idea of these 
methods. The first lesson we learn from these brief, 
but expressive paragraphs is, that we are to observe this 
man, who " is plainly always in motion," and that we 
are not to be satisfied with the observations of another. 
Then follows the natural sequence in these observa 
tions. At first the gross expressions of the body, and 
the difference between the man awake, asleep, dead 
ISText a "more careful observation," determining the 
motion of the heart, etc. And lastly, the skilled obser- 
vation, from a trained mind, aided by the various in- 
strumentalities and appliances of science. 

Books are useful in this study, though not the object 
of study ; it is the man we want to know, not the book 
nor its author. The book may serve as a guide-board 
pointing the way, and at the same time give us a 
standard of comparison. It tells us what to exercise 
our senses upon — what to observe — and it informs us 
what others have observed, and what is the common 
standard of healthy activities. 

There is nothing in the life of the man but should 
be a subject of close scrutiny. We want to know him 
in the entirety of his action, as we wish to know him 
in every detail. And we want to know him so inti- 
mately and thoroughly, that this physiological man 
shall be always present with us as a standard of com- 
parison. 






24 STUDY OF DIAGNOSIS. 

The reader will at once see the necessity of this study 
as a basis for diagnosis. The physiological man is the 
man of health, the pathological man is one who has left 
this common standard of being. The physiological 
man is the standard of measurement, the common mean 
that we measure from. To have a measurement at all, 
it is necessary to have a fixed point to start from ; this 
healthy man is the fixed point. 

Measurement has reference to certainty, and certainty 
is what we most desire in medicine. A measured mile 
is a definite distance, an imaginary mile, having its 
origin and termination in the cranium of Paddy 
Ochhone, is a very different thing, though very like the 
ordinary measurements in medicine. 

The first thing that the physician wants, then, is a 
sound physiological standard, which he carries with 
him as he makes his rounds. It is lain by the side of 
the patient in bed, sits by him on the chair, stands by 
him, walks by him, puts out its tongue, extends its 
hand to give the pulse, has lungs, bowels, kidneys, re- 
productive apparatus, etc., always at your service, and 
open for comparison. 

Disease is wrong life, and a wrong presupposes a 
right. To determine the existence of a wrong, we must 
know what the right is ; to determine the character of 
the wrong, we must compare it in all its parts with the 
standard right. This is diagnosis, as the reader can at 
once see. 

How now shall we get this physiological standard. 
Clearly by observation with our own eyes, and the use 
of our own senses. Each man must make it for him- 
self, and give it distinctness by the education of his 
own senses. Theoretical knowledge will not do. 



STUDY OF DIAGNOSIS. 25 

If we take Huxley's first example, " awake, asleep, 
dead," we find an excellent study. Can you tell the 
difference between the appearance of sleep, sleep and 
death ? Hardly by the first glance, and possibly only 
by a very close examination, and some experimenta- 
tion, (the last especially evidences a state of uncer- 
tainly). But if we carefully observe the phenomena 
of sleep, in the infant, the child, the adult, we will soon 
have a healthy standard, and the expressions of sleep 
are so distinctive, that no one could deceive us by 
shamming sleep. 

So, too, if we carefully observe and study death, we 
will never mistake it. There are distinct expressions 
of body in death that can never be counterfeited. It is 
not only the absence of motion, of respiration, of pulse, 
or heart-beat, of heat, but there is an absence of the 
expression of life in its totality, and an expression of 
lifelessness that is characteristic. The relaxation of 
death is distinctive, as is the rigor-mortis, as is the de- 
composition of tissue. 

It is a good thing to have a standard of death for 
comparison as well as of life. Not that we usually 
have any doubt of death, but that we require it as a 
measure of life. It is well to have two j^oints to mea- 
sure from — the standard of life and the standard of 
death. There is an approximate death, as well as a 
total death ; a dying by degree, or part, as well as a 
dying at once and in entirety. 

Taking a man in entirety, we find a distinct expres- 
sion when he walks, stands, sits, or lies. Every part 
of the man talks to us, his hands, his arms, his legs, his 
feet, even his "calves may wink," as described by 
Dickens in one of his Christmas stories. 
3 



Zb STUDY OF DIAGNOSIS. 

We not only learn from this much of the physical life 
of the outer man, but, learn of the life within. The 
expression is the shadowing forth of the underlying 
nervous system, and this again of the real or spiritual 
man behind this. As physical, mental and moral 
health has a distinct expression in the outer man, which 
we purpose using as a standard of admeasure ; so all 
diseases, physical, mental and moral, have a distinct 
expression in the outer man. You will no more find 
disease under a healthy exterior, than you will find a 
devil in the garb of an angel. 

We have a standard temperature, which we may 
learn to recognize by the hand, though it is best to 
measure it with a thermometer. We have a standard 
electrical condition as an important factor of life, which 
we will learn to recognize in the general expression 
and movement, the special expression of the face and 
eyes, and by the touch. And we have a standard 
formative force, which we will recognize in the expres- 
sion of tissues, and the sensations they give to touch. 

We have a standard color for th<e general surface, 
and for special parts that the eye will learn to recog- 
nize, and use for comparison. We make this study 
thorough ; it is the skin at large, and then those por- 
tions where the circulation is less free, where it is very 
superficial and free, the nails, hair, veins, etc. We have 
a standard color for mucous membranes, for lips, gums, 
tongue, teeth, etc. 

We have a standard in touch — of smoothness, resist- 
ance, elasticity, size and association ; and we have it of 
every part of the body. Of course we have not learne-l 
it of Huxley or Carpenter, but by the use of our own 
hands on the human body. 



STUDY OF DIAGNOSIS. 27 

We have a standard respiration, in frequency, full- 
ness, depth and freedom, which is distinct and clear, 
and which we know of ourselves by observation. 

We have a standard circulation, which we know at 
the radial artery, by the even, distinct, regular blood 
wave that passes under our finger, as well as by the ex- 
pression and color of the surface, and the expression of 
parts associated with the heart in action. 

We have a standard condition of the digestive organs, 
which we learn from books and by observation. It 
don't take long to learn, even by the general expres- 
sion, and the special expression of the muscles of the 
mouth, whether a man has a good appetite, good diges- 
tion and good blood-making. Even constipation will 
be shadowed forth in the outer man so that one may re- 
cognize it. 

Blood-making and nutrition must have distinct ex- 
pression, and a standard for measurement will be readily 
formed, for all functional activity is dependent upon 
nutrition. 

The standard of healthy excretion by skin, kidneys, 
and bowels is readily formed by observation, Not ob- 
servation on the sick, and under the influence of drugs, 
as many suppose, but upon the well. 

Thus we see it is possible to so learn our physiology, 
that it may serve as the basis of a rational practice of 
medicine. And I think every reader will see that this 
education is essential to good diagnosis, and that its at- 
tainment is the first object in medicine. This is not a 
question of schools ; it is a question of sheer empiri- 
cism, (call it quackery if you will), or rational medi- 
cine ; it is a question of whether the physician is to be 
a coadjutor and aid to death, or whether his influence 
will be upon the side of life and health. 



28 STUDY OF DIAGNOSIS. 



METHODS OF DIAGNOSIS. 

Where do we find the expressions of disease ? When 
you think of this question a moment, it does not seem 
so easily answered ; indeed it furnishes good material 
for thought. Probably we had better preface it with 
another. How do we find the expressions of disease? 
Man has knowledge of things external to him, by means 
of the general sense of touch, and the special senses — 
sight, hearing, smell, taste. We may ask, then, when 
brought in contact with the sick, what do we feel, see, 
hear, smell, taste, that differs from the normal condi- 
tion — health. What the patient feels, sees, hears, smells 
and tastes is not so important, for his senses are im- 
paired by disease, they have never been educated, 
and his mind is not in a good condition to receive im- 
pressions. 

I imagine the reader saying to himself — well — really 
— I don't know about that. I don't feel my patients 
much, and am not sure that I learn much by feeling. I 
see them — but — I don't know that I can tell the char- 
acter of disease, by sight. I hear — yes — I hear all the 
patient has to tell me about his bowels, number of ope- 
rations, whether he passes wind up or down, or both, 
makes water, where he has aches and pains, etc. I 
don't smell much, unless I examine the bed-pan or 
chamber utensil, and I don't want to taste in the sick 
room. That is — he makes his diagnosis, from the 
patient's feelings, and not by the use of his own senses 
— a very imperfect way of making a diagnosis. 

We have called attention to the uncertainty of diag- 
nosis from " what the patient says," yet it is the com- 



STUDY OF DIAGNOSIS. 29 

mou means of diagnosis with all schools of medicine. 
If the patient was wholly truthful there would be suf- 
ficient uncertainty, for they have little knowledge of 
disease, little skill in observation, and from disease they 
are incapacitated for reasoning. The patient can not, in 
the very nature of the case, know very much of his dis- 
ease, and does not know that little well. 

II now we supplement this by the well known ten- 
dency to exaggeration by the sick and friends, we find 
still more uncertainty. You ask when you visit a 
patient whether he slept. The wife answers — " not a 
wink," and yet you know from the patient's expression 
that he has rested during the night, though his sleep 
may have been broken. Or the nurse answers, " Oh, 
yes, he had a good night's rest," though the only 
ground she has for supposing so is because she slept 
herself, but the patient's expression shows you he has 
passed a restless night. You ask if the patient has 
taken food — " no, he hasn't been able to take a bite," 
though you find on persistent inquiry, that he has had 
broth, or milk in sufficient quantity. You ask if he has 
passed urine — " Oh, yes, sufficient," yet you see by the 
pinched, anxious countenance, and position of abdomen 
and pelvis, that he is suffering from retention or sup- 
pression of urine. You ask if the patient suffers much 
— " Oh, yes," is the reply, " I have had severe pain," 
or "I have suffered intensely," yet you see by the 
countenance that the statement is false or overdrawn. 

I do not believe that my patients are worse in this 
respect than others, yet I have occasion to say to 
myself every day, when listening to the patient's or 
nurse's story — " Madam, or sir, you are lying." Indeed, 
I have always made it a rule to believe nothing that 



30 STUDY OF DIAGNOSIS. 

was told me in a sick room, unless it was corroborated 
by my examination of the patient. 

I have tried the experiment several times, of seeing 
how far the patient and attendants would go in their 
exaggeration. Take one that is imaginative, and by 
leading questions and promptings you can get the 
symptoms of every ailment to which man is subject ; 
and the story will have more consistence and semblance 
of truth, the more the patient knows of disease. The 
nurse is frequently as bad as the patient in this respect, 
and quite as easily led to exaggeration. I had an illus- 
tration of this a few weeks since in the person of a 
monthly nurse. The mother and child were doing well, 
yet you would think from the nurse's description that 
they were just on the point of having every ailment 
that the puerperal state would afford. The mother was 
not easily influenced, or the nurse would really have 
made her sick. 

Why has a good physician better success in diseases 
of children than in other cases ? There is no doubt of 
the fact, and I have heard it remarked many times — 
" I would much rather treat children than adults — 
medicines act better." You can't question the child, and 
you learn but little that is important from the mother — 
how do you get your information ? True, the mother 
and friends will say — i( it is so hard to doctor children, 
yon can't find out what is the matter with them." But 
a good practitioner knows better than this, and though 
possibly he has never thought about the subject, he 
knows he can treat children better than grown persons. 

"Why ? For the very good reason that he uses his 
senses, and prescribes from what he knows, instead of 
inking the say-so of patient or nurse as a basis for the 



STUDY OF DIAGNOSIS. 31 

prescription. If I should suggest to you, that in the 
practice of obstetrics you should place dependence 
upon the statement of nurse and patient, instead of 
making an " examination "—you would think it most 
absurd. Yet, in reality, it is not more absurd, than de- 
pending upon the story of nurse and patient in ordi- 
nary diseases. 

If these are facts, and I think the experience of every 
reader must satisfy him that they are, we want to 
change our method and get a better basis for diagnosis 
and prescription in diseases of the adult. Let us sup- 
pose every patient a child — which they are in fact, so 
far as medicine is concerned — and give them the same 
careful examination that we would to the child, and 
thus reach conclusions from what we know, rather than 
from what patients or nurses say. 

We do not wish to lose the advantage of any infor- 
mation we may get from patient or nurses, but we pro- 
pose to make no suggestions in the manner or charac- 
ter of questions, that will bring false answers. There 
are. some things the patient will know, and a little care 
will frame the questions so as to get at the real facts. 
There are some things the friends or nurse will know, 
and direct questions will usually bring straight replies. 
But there are many things that neither can know any- 
thing about, at least with any certainty, and these 
should always be avoided, 

All answers should pass in review of our own senses, 
and what we know of health and disease. These are 
the judges, and if the evidence is good it will have their 
approval ; if it does not have their approval Ave throw 
it to one side. We do not purpose receiving anything 
thH is opposed to what we know of disease, and we do 



32 STUDY OB DIAGNOSIS. 

not purpose believing anything that is opposed to the 
evidences of our senses. 



THE EDUCATION OF THE SENSES. 

We have already seen that the education necessary 
to make a good physician, is not from books, or of the 
memory— both good in their place, but insufficient. 
The education that gives the best results, and makes 
the successful practitioner, is of the senses, and of the 
brain to receive impressions, and make deductions. 

We have called attention to the proper study of an- 
atomy, by which one may hnoio the structure of the 
human bod} T of himself; and the right study of phy- 
siology, by which one may know the various activities 
of this mechanism. To make these attainments re- 
quires study — not midnight oil burned in reading 
books, but the continuous exercise of our senses upon 
the human body, living and dead. 

The same course of study is necessary to know dis- 
ease. The description from Aitkin, Wood or Scudder, 
is not the knowledge we want ; it is not what another 
man knows that is of advantage to us, any more than 
it is another man's dinner that sustains our life. We 
want to know disease for ourselves, and we learn it by 
the exercise of our senses upon diseased bodies. 

If the senses, then, are the instruments by which we 
obtain knowledge, it will at once be patent to the reader 
that their develoj)ment and goodness will be the mea- 
sure of our ability and our attainments. Hence the 
man of educated and acute senses will be far superior 
to and have every advantage over the man who has not 
been thus trained and developed. 



STUDY OF DIAGNOSIS. 33 

Most persons seem to think that the human senses 
arc natural, not acquired — that they are born to us, and 
not the result of education. This is a very great mis- 
take, and a grave error to the physician. Man is born 
with an organism that, so tc speak, has germinal capaci- 
ties for use, and its future development is by normal 
use. The child at birth has perfect hands and arms, 
every bone, muscle, bloodvessel and nerve being there ; 
but they arc as yet wholly useless. Its feet and legs 
have all the parts of the adult, but it can not walk, or 
even wag its toes under the influence of the will. Its 
eyes are perfect, yet the images formed upon the retina 
are wholly without meaning, and might quite as well 
be a blank. 

The child slowly learns to use its hands, and months 
pass before it can hold an object, and a still further time 
before it can move the object in obedience to the will. 
We see it day by day learning to see, slowly taught by 
its surroundings. And the adaptation of the nether 
limbs to walking is the persistent work of the first 
twelve or sixteen months. Compare the child of these 
attainments of one year with the child of two years, 
and you see a wonderful difference. The education has 
been continually going* on during this period, and with 
continued use in right directions comes increased devel- 
opment. At the third year there is further improve- 
ment, and thus, as we go on to the fifth, the tenth, the 
twentieth year, we observe a continued education of 
the senses, and a better development of them. 

I want to call attention to the fact that we find every 
grade of development in different individuals, from the 
first year up to maturity, and that this development 
does not always depend upon the original capacity. A 



34 STUDY OP DIAGNOSIS. 

difference in use or in education, so to speak, gives dif- 
ferent capacities. It is not in the initial or starting 
point, but in the method of progress, that gives the 
fully developed sense. If the child has been rightly 
directed, and the senses have been rightly used, they 
w'll have proportionate capacity. 

Many who would admit that the human senses'are 
aeruired, think of them as being acquired very much 
as the man increases in stature and weight, and some- 
thing essentially belonging to this period of growth. 
They conclude that the senses grow with the body, and 
attain maturity when it has reached the full size and 
stature of a man ; and now a man, having his full 
capacity, will find neither increase nor diminution so 
long as he may live. They measure a man in all his 
parts in this way ; his every function is now developed 
for life. A greater mistake could not. be made. 

The law of develojnnent is always in operation in the 
human body, as it is throughout the animal and vege- 
table world. As any organ or part is rightly used, it grows 
in capacity. Not only in infancy, in childhood, up to 
adult years, but each and every year of a man's life to 
old age. It is more marked, of course, when the repro- 
ductive powers are active, but it is always a law of life. 
The man between thirty and forty years, will find that 
he still has the germs of a large capacity, which needs 
but the right use for development. He may grow legs, 
arms, body, chest, lungs, brain, the sense of touch, of 
taste, of smell, of hearing, of sight, if he will; all that 
is necessary is, that he should rightly use that he has. 

Shakspeare makes his typical Dogberry say, 

"To be a well-favored man is the gift of fortune; 
But to write and read comes by nature, ; ' 



STUDY OF DIAGNOSIS. 35 

But however it may be with reading and writing, very 
surely acute sight, smell, taste, hearing, touch, do not 
come by nature. We all recollect the tedious process 
of education — how we slowly attained our A, B, C's, 
and what a work we had done when we could spell b-a 
ba, k-e-r ker, baker — and so on through, whether it has 
been little or much. This is the type of education, and 
this is the way it is obtained — little by little, and by 
continuous application. 

But there is another view of the question, quite as 
important to many persons. The law is not only ope- 
rative in the one direction — to increase functional 
capacity — but quite as much so in the other direction — 
to lessen or take away that we have. The part or organ 
disused loses its functional capacity, becomes atrophied, 
and finally loses the power of reproduction— is wholly 
gone. The Indian Faakar, who vows to hold his arms 
above his head, finds after years are passed, that they 
are no longer obedient to the will, are lost. This is the 
case with any part of the body — with the organs of 
special sense, and with the brain and its functional ac- 
tivities. It is the application in the human body of 
Christ's parable of the talents : 

" For the kingdom of heaven is as a man traveling 
into a far country, who called his own servants, and de- 
livered unto them his goods. And unto one he gave 
five talents, to another two, and to another one; to 
every man according to his several ability ; and straight- 
way took his journey. Then he that had received the 
five talents went and traded with the same, and made 
other five talents. And likewise he that had received 
two ; he also gained other two. But he that had re- 
ceived one, went and digged in the earth and hid his 
lord's money." 



36 STUDY OF DIAGNOSIS. 

The reader will recollect the application of the para- 
ble — the one who had used his talents found them in- 
creased ; the one who buried his, had taken away from 
him that which he had. The divine Teacher enunci- 
ated a law as wide as the universe, and as applicable to 
physical and mental growth, as to moral development. 
It is just as applicable to the training of the senses of 
the physician, as it is to the growth of the moral nature 
of man. The lesson is clear : if we want anything, we 
must work for it ; if we will not work, we lose that we 
have. 

Man has conscious life in his brain and through his 
senses. Take away his senses, and he has lost all com- 
munication with the world without. Through his 
senses he has pleasurable life, and it is deep and broad 
in proportion to their development. One would think 
that this would be sufficient incentive to their full de- 
velopment. But, unfortunately, men dislike work, not 
realizing that even this will prove a pleasure. 

It is the continued and orderly exercise of parts that 
gives them increased capacity. Not by fits and starts, 
but continuously, day by day, week by week, month by 
month, year by year. The organs of special sense have 
in them a mechanism for skilled use, as well as for the 
gross purposes of life, and it is this skilled use we pur- 
pose to call forth in diagnosis. 

Man has five senses — of touch, of sight, of hearing, 
of smell, of taste — all of which are useful in this study, 
and all require training. The pl^sician of unskilled 
touch, sight, hearing, smell, taste, can never be suc- 
cessful. It is hardly necessary to give examples of 
this, as every reader's experience will show it a truism, 
but a few may stimulate thought. 



STUDY OF DIAGNOSIS 37 

In the obstetric art the skilled touch is the important 
element of success to the accoucheur. Without it he is 
groping in the dark, and is obliged to sit passively by 
the bedside and wait. He can not know, and of course 
can not give intelligent assistance when assistance may 
be required. In the same way the unskilled touch 
could never use a knife in surgery, could not pass a 
catheter, could not recognize the variations of the pulse, 
could not determine the condition of the skin, could not 
do a great many things that might be done if the touch 
were educated. 

The untaught eye can not distinguish the variations 
of form, size, color, and other physical properties of 
bodies, which tell of condition, and functional activity. 
To the extent that it is uneducated the man is blind. 
and of necessity is groping in the dark. 

The untaught ear has no use for the beautiful median- 
ism that adapts the organ to receive the varied impres- 
sions of sound. It can hear thunder, and it can hear 
noise, but to the " concord of sweet sounds " it is deaf. 
In medicine the ear requires education by use in order 
to detect some of the minute sounds, as the " respira- 
tory murmur," and a still further education to detect 
the minute shades of difference in sound, which tell of 
disease 

The same may be said of the educated senses of smell 
and taste. The uneducated nose may recognize the 
genus stink, but has no power of analysis ; as it may 
recognize fragrance, and have no pleasure from it. To 
the uneducated taste all substances are savory, or un- 
pleasant, and with this gross classification the sense is 
satisfied. To the educated taste there is every grada- 
tion of the one and the other, and a power of discrimi- 



38 STUDY OF DIAGNOSIS. 

nation that is sometimes really wonderful in its acute 
ness. 

How may we Cultivate the Senses? — This is the 
really important question, though the answer has been 
partly given in the above study, We cultivate the 
senses by continuously using them, and their education 
is the work of months and years. We can always find 
objects to exercise them upon, the training school is all 
about us, and we have only to make intelligent use of 
the facilities at our command. It is well, however, to 
have an intelligent plan, and follow it up assiduously, 
recollecting that " time, patience and perseverance will 
accomplish all things." 

The senses ara intimately associated with the brain, 
and their education implies a mental training as well. 
Whilst we develop) the organ of sense by use, we develop 
the brain upon which the impression is made, and the 
higher brain which takes cognizance of, and analyzes 
the sensations. The development is thus a double one, 
and both are essentials in correct diagnosis. A plan 
presupposes thought, the act of the rational mind, as 
well as orderly activity.* 

■-Sensations and Judgment. — (That the reader may have 
before him a brief synopsis of the physiology of sensation, I give 
the following description from Huxley's Physiology:) 

"In explaining the functions of the sensory organs, I have 
hitherto confined myself to describing the means by which the 
physical agent of a sensation is enabled to irritate a given sen- 
sory nerve ; and to giving some account of the simple sensations 
which are thus evolved. 

" Simple sensations of this kind are such as might be produced by 
the irritation of a single nerve-fibre, or of several nerve-fibres 
by the same agent. Such are the sensations of contact, of 



STUDY OF DIAGNOSIS. 39 

The Touch. — The tactile sense has its highest de- 
velopment in the hands, and it is in this locality, espe- 
cially, that we purpose cultivating it. Delicacy of touch 
is associated with a normal condition of the skin, and 
necessitates care of the hands. It does not mean a life 
of idleness, but it means proper protection from cold, 
cleanliness, and an avoidance of such work as thickens 
the epidermis, or gives it unnatural hardness. " Clean 
hands and a pure heart " is a gospel expression that 
we can well apply to medicine, both essentials. Show 
me the physician with rough, unpleasant, grimy hands, 
and I will show you the man who is unsuccessful in his 
calling, and is being gradually imbruted in his nature. 
The hand is the characteristic feature of man, and is 
the outer expression of the reason within, and the 
spirit that is above the beast. A French writer once 
remarked, " Show me the man's hand, and I will tell 
you what manner of man he is." 

A plan of use ? It suggests itself at once — we will 
exercise our touch upon every object we come in con- 
tact with. Here are objects large and small, long and 
short, rough and smooth, of varied form, with special 
Inequalities of surface, of varied consistence, and we 



warmth, of sweetness, of an odor, of a musical note, of whiteness, 
or redness. 

" But very few of our sensations are thus simple. Most of 
even those which we are in the habit of regarding as simple, are 
really compounds of different sensations, or of sensations with 
ideas, or with judgments. For exa.mple, in the preceding cases, 
it is very difficult to separate the sensation of contact from the 
judgment that something is touching us; of sweetness, from the 
idea of something in the mouth; of sound or light, from the 
judgment that something outside us is shining, or sounding." 



40 STUDY OP DIAGNOSIS. 

purpose feeling them until we can recognize them as 
well in the dark as in the light. 

We take the bones of the skeleton, and learn to re- 
cognize them hy the touch as well as by the sight. Our 
Profs. Freeman or Howe will tell you the bones as well 
by touch as by sight. We take the dead body, and 
train the touch to recognize every part, by its form and 
resistance. We lake the living body, and learn to re- 
cognize the impressions given by the skin, fasciae, mus- 
cles, bones, and by the cavities of the body. 

Attention has already been called to the necessity of 
the skilled touch in the obstetric art. You know a ver- 
tex presentation by the impression made upon the fin- 
gers brought in contact with the head. You determine 
fontanelles and sutures in the same way, and thus know 
the position. The nates give a different impression, 
and the finger recognizes the genitalia of male and 
female, as additional evidence. It recognizes a shoulder 
or elbow, a hand, a knee, or foot. How? Not intui- 
tively ; we have no natural knowledge of this kind, it is 
cultivated. Shall we wait until in obstetric practice we 
learn and acquire a skilled touch ? That would be very 
bad policy, especially for our j^atients. The sense of 
touch is first trained by general use, and then we find 
opportunity upon the child already born, to acquire the 
knowledge of how a cranium, suture, fontanelle, nates, 
genitalia, shoulder, elbow, hand, knee, foot, feels — it is 
easy enough to find the opportunity, if one is inclined 
to learn, and it is easy to get this necessary skill in 
obstetric diagnosis if one is inclined to improve his 
opportunities. 

Sight. — The sense of sight is one of the most impor- 
tant in diagnosis, and it, like others, requires education, 



STUDY OF DIAGNOSIS. 41 

both as to the eye which receives and the brain upon 
which impressions are made. The eye receives im- 
pressions of color, and by education learns to detect 
the form, size, distance, and many of the physical prop- 
erties of objects. 

Color being one of the prominent characteristics of 
health and disease, the ability to accurately distinguish 
colors must be a great aid to the physician. The un- 
educated eye receives the impress of color very much 
as it does light and shade, attaching about the same 
meaning to it, but when trained by use, it readily de- 
tects slight variations. 

It is quite easy to form a cabinet of colors, from 
natural objects which may be studied in detail, and 
this is suggested to the reader in preference to giving 
the color sheets here as first intended. The vegetable 
and insect worlds furnish them in great abundance, and 
specimens can be readily preserved. Quite soon the 
eye has learned to distinguish color from light and 
shade, and in a few weeks will become quite skilled, 
and yield much pleasure by the habit of observation 
thus acquired. There is nothing trivial in nature, and 
nothing so poor or worthless that it should not be 
known ; this is especially true to the physician because 
he must be a student of nature, to be able to deal with 
nature's greatest work, the human life. 

The practical education of the eye to color is com- 
pleted upon the human body. We find distinct varie- 
ties of color in health — of skin, of mucous membranes, 
of parts where the circulation is superficial, showing 
arterial blood, of veins, of the e3 T e, the nails and the 
hair. We want to learn to know the healthy man by 
his color, and we may know him by this. 
4 



42 STUDY OF DIAGNOSIS. 

There is also abundant opportunity to educate the 
eye to the variations of color in disease, so that they will 
be readily recognized, and their true meaning known. 
We may procure types of these morbid colors, so that 
we will be enabled to refresh the memory with them. 
Some of these will be given further along in this work, 
but the reader is advised to select samples of other 
colors for himself. 

The training the eye to the detennining of size is not 
so important, } T et will be found quite useful. One phy- 
sician will recognize a swelling, which evidences local 
disease, which another lias failed to notice. So one 
will recognize a fullness of skin, of cellular tissue, of 
mucous membrane, of tongue, which another fails to 
see. 

Training the eye to recognize form is very important, 
both to the physician and surgeon. The trained eye 
of the surgeon at once detects a deformity, and deter- 
mines its cause, whether from fracture, dislocation, or 
structural disease. The trained e} T e of the physician 
should be able to recognize at once the general form of 
health, in the posture and expression of the patient, 
and the evidences of disease in the changes of form, in 
position, in sitting, lying, in the position of the limbs, 
and in the expression of the features. The trained eye 
recognizes changes in the form of the tongue, which 
express conditions of disease, and call for special reme- 
dies. 

Hearing. — Physicians do not seem to have realized 
the importance of the ear in diagnosis. It is true that 
we have a system of physical diagnosis for diseases of 
the chest, which the student is advised to learn ; but. 



STUDY OF DIAGNOSIS. 43 

unfortunately, the advice is not supplemented by the 
lesson we are trying to teach — that these organs must 
be educated. The studeut applies his untrained ear, 
and hears nothing, or is unable to distinguish variations 
in sound, and becoming disgusted, gives physical diag- 
nosis over to the expert or the specialist. Even if he 
persists in trying to learn, he finds that he can not hear 
the sounds described in the books, (simply because there 
are no such sounds produced),, and is thus discouraged. 

All nature is vocal with sound, and the sounds are 
the expressions of life. The old Hebrew poet recog- 
nized this fact, and gives expression to it — even " the 
morning stars sang together." All nature is vocal with 
sound, but to the uneducated ear it might quite as well 
be still, for it expresses naught to him. Train the ear, 
and educate the brain, and we have a " concourse of 
sweet sounds," taking the entire range of life, express- 
ing all its feelings, its hopes, its fears, its griefs, its 
cares, its pleasures, its pains. It recognizes the love 
song of the bird, the tone of wedded bliss, the gush of 
parental affection, the cry for assistance, the shriller cry 
of assault, the song of victory, the wail of defeat, and 
the moan of death. 

There is a fascination in the study of sound when 
once commenced, that will carry the observer on, and 
he will find a continued reward from it. If we take up 
the single study of the expression of animals in their 
cry, we find it of wonderful interest. We learn to re- 
cognize the speech of bird and beast, though we may 
not have slept with the fairies, as did the little boy of 
old. The cry of pain in the animal kingdom is so ex- 
pressive, that it will be recognized at once, and pretty 
soon we will find ourselves locating and giving charao- 



44 STUDY OF DIAGNOSIS. 

ter to the disease by this expression. One of the most 
striking examples of this I have ever witnessed, was in 
the case of a pet goat that was poisoned by eating 
paint. The cry was as expressive as that of a child, 
and one involuntarily located the wrong in the intes- 
tinal canal — it was lead colic. 

" Ears ye have but ye hear not," is applicable to the 
physician in ordinary. He is diligent in questioning 
the sick, and seems to think there is wisdom in the 
thoughts of the poor sick brain. The expressions of 
the voice, which tell the condition of the brain, and of 
the life of the man, to a considerable extent, is never 
heard, the doctor is deaf. 

In auscultation, the first lesson is in learning to hear. 
It requires close and continued study to hear the respi- 
ratory murmur distinctly, and this study must be con- 
tinued if we expect to recognize the variations of this 
and the sounds produced in the bronchial tubes. Skill 
in physical diagnosis does not come by nature ; it is the 
result of study, and the education of the ear and brain. 
No man can expect to succeed in it unless he is willing 
to give months to it, first to educate the ear to the hear- 
ing and analysis of sound, and next to the hearing and 
analysis of the sounds heard in the chest. 

Smell. — Of still less importance is the sense of smell, 
and yet it has its place in diagnosis. A good nose is a 
good thing, and the sense of olfaction should not only 
be a safeguard to the individual, warning him of noxious 
influences, but should be a source of pleasure as well. 
To some extent this sense is instinctive, especially as it 
warns against irritant substances, and leads to their 
avoidance. But it is one that may be educated to a 



STUDY OF DIAGNOSIS. 45 

very high degree. We have examples of this in some 
varieties of merchandising. The wine merchant grades 
his fi-ine by its boquet, as well as the taste. The tea 
dealer will classify his wares, and price them, by their 
odor, as will the fancy grocer with a majority of the 
edibles he deals in. 

We want a good nose for the purposes of diagnosis, 
and we especially want a good nose that it may look 
after the hygienic surroundings of our patients. There 
is an abundance of bad smells about the sick room, 
some peculiar to the condition of disease, and some the 
result of want of cleanliness and ventilation. We want 
to know them, and to do so we require an educated 
nose. 

What is an educated nose ? It is one so trained by 
use that it transmits sensations to the brain, which has 
also been trained by use to receive and analyze them. In 
other words, it is the association of brain and nose in 
the work. This sense is educated in the same manner 
as the others. We find odorous objects, and use this 
sense in their cognition. Pursuing the study we learn 
to discriminate between odors, and to recognize them 
immediately, *\nd the character or condition of bodies 
they express. 

It will require but little training to enable this sense 
to detect the unpleasant surroundings of a patient. The 
first impression of the air of the sick room tells of a 
want of ventilation, of a deficient supply of oxygen, a 
superabundance of carbonic acid gas, and a surplus of 
foul gases. The nose not only recognizes these wrongs, 
but will insist upon their abatement. It says, open the 
windows and doors, let in the sunlight, build an open 
fire, and wash up. There is no mistaking the .language, 



46 STUDY OP DIAGNOSIS. 

and the physician feels that he must carry out its 
orders. 

It recognizes a want of bathing upon the part of the 
patient, dirty clothing, dirty bed-clothes, a foul chamber 
utensil under the bed. dirty dressings, dirty or bad 
food, dirty medicines, and says in unmistakable lan- 
guage, get these things away. " Cleanliness is next, to 
godliness,*' and of far more importance in the recovery 
of the sick. 

It will also point out conditions of disease, and talk to 
you of special medicines. It says, typhoid, sepsis, loss 
of life and breaking down of tissue plainly; and sug- 
gests for your consideration an individual of the group 
antiseptic — chlorate of potash, sulphite of soda, sul- 
phurous acid, carbolic acid, baptisia, permanganate of 
potash, etc. 

Taste. — Whilst the sense of taste is a good thing, 
and should be well cared for, we do not propose to 
make much use of it in medicine. It is well, however, 
to use it upon the food prepared for the sick, because 
we find a great many wrongs here. People have not 
lost the old impression that the sick need no food, and 
that it makes but little difference what kind is given, or 
how it is prepared. If the physician does not look 
after this, he will find many times that his patient is 
being starved because food is unpalatable, or so badly 
prepared that it is indigestible, or so changed in char- 
acter, that it really does the patient a wrong. 

If the physician has a right appreciation of the ne- 
cessity of good food, and the nurse or friends .know 
that he will make it his business to look after it, and 
see that it is well prepared, they will probably use 



STUDY OF DIAGNOSIS. 47 

more care, and will ask for information when it is re- 
quired. 

There are some things that the physician" will do well 
not to cultivate a taste for or in. He should not be a 
connoisseur in liquors. It is far better that the patient 
ran the risk of getting bad whisky, brandy, or wine, 
than that bis medical attendant should have acquired 
the ability to determine for him. If there is any one 
road shorter than another to want of success, loss of 
character, poverty and wretchedness, it is the habit of 
tippling. The road seems especially broad, smooth and 
direct to the doctor, and he may well apply the old 
Latin quotation from Virgil : "Facilis descensus Averni" ; 
and the second line — " but to escape is indeed a work 
of difficulty." 

We have thus briefly examined the means by which 
one is prepared for the practice of medicine. The 
reader will have noticed that we place great stress on 
self-education, as the basis of skilled diagnosis and 
therapeutics. All knowledge is available in medicine, 
and we do not wish to depreciate the ordinary medical 
course of study, and would advise that the study of 
medicine and the collateral sciences should be carried as 
far as possible — and it is possible, even with the busiest 
man, to make very considerable attainments outside, as 
well as inside the range of studies usually pursued. 
Still, unless the physical organism be trained to use, 
our other education will prove a dead letter. It is the 
means that brings man in relationship to, and gives him 
cognizance of his surroundings and the world at large. 
He not only has knowledge of things through his 
senses, but his practical knowledge is in proportion to 
their education and acuteness. 



48 STUDY OP DIAGNOSIS. 

In the study of disease it will be best to change the 
order in which we have noticed them here. The phy- 
sician sees his patient first, and then the examination 
commences with the sight, touch, hearing, smell, taste. 
This may be regarded as the natural order, and we will 
observe it in the further study of the subject. 



THE USE OF THE SENSES IN THE DIAG- 
NOSIS OF DISEASE. 

It is well to notice that we have a two-fold object in 
studying. We wish to determine the locality and 
nature of disease — its pathology ; but we also wish to 
determine those agencies which will oppose disease and 
restore health — its therapeutics. These are both im- 
portant studies, and we do not wish to neglect either, 
yet the reader will see that the last is the practical one. 
If we can determine what will cure, we have accom- 
plished the important object ol medicine. 

The means of cure have held a secondary place in 
medicine, and indeed it seemed sometimes that it held 
no place. Physicians would be very learned as to 
pathology, and able to divide and subdivide the lesions 
of function and structure until they would be " an im- 
mense multitude," yet you could count their remedies 
upon your fingers, and these were of the olden time, 
devitalizing, and most absurd. You would find an im- 
mense volume on pathology and diagnosis, teeming 
with wisdom, and a therapeutics meager and feeble in 
everything but its power to do harm. 



STUDY OF DIAGNOSIS. 49 

Id this study we wish to make therapeutics occupy 
the first place, and the diagnosis will mean remedies^ 
whenever this is possible. We do not care so much to 
affix a name, by which the wrong may be known, as to 
prefix a remedy by the means of which the disease will 
not be known. Or to put it in plainer form, the object 
of examination is to determine what will cure. 

It is my opinion that we can so study disease, that 
its symptoms or expressions will talk to us of individual 
remedies, and in language so plain that it can not bo 
misunderstood. As this is the first object of study, we 
will keep it constantly in view. 



DIAGNOSIS BY THE EYE. 

The educated eye requires no prompting to do its 
work in the examination of the sick — its training is to 
this end. It takes in the appearance of the patient and 
his surroundings in all their detail. An effort of the 
will is required to make the mind attentive, and to co- 
ordinate the impressions, and reach conclusions from 
them. 

It would seem unnecessary to say that many conditions 
of disease find outward expression through the muscu- 
lar system and its investing connective tissue and skin, 
and that the physician should recognize them as soon 
as his eyes have made their examination, and yet the 
study of medicine is pursued as if this were not so. 
The doctor is very eager to see the patient's tongue and 
feel his pulse, and ask all manner of questions pertinent 
and absurd, but he is blind to these natural expressions, 
or if he learns, it is slowly and because the facts are 
5 



50 STUDY OP DIAGNOSIS. 

forced upon his consciousness. The reason is obvious — 
his attention has never been directed to it, and he has 
failed to study the subject as it was presented to him 
in practice. 

This study requires an exercise of the mind, and that 
the reader may commence thinking to advantage, we 
will take some very familiar examples in the animal 
kingdom. Let us see, for a moment, how animals ex- 
press emotion (the action of the mind in so far as it is 
developed). If you notice your dog or cat for a few 
days, you will see the clear expression of the entire 
range of the emotions, anger, fear, love, hate, joy, grief, 
consideration, conclusions reached, etc., and so plainly 
that you can make no mistake. Examine your horse, 
and you will find the same clear and striking language 
of expression. It is really wonderful, this voiceless 
language of animal life, and well repays study. 

Supposing now we study the expression with refer- 
ence to rest. You notice the dog taking his siesta, and 
carefully scan his posture and feature, and the idea of 
rest is so strongly impressed that you are sure you 
could not be mistaken. Whistle sharply, and notice the 
change to a position and expression of activity and ex- 
pectant attention. Give his ear a sharp pinch, and you 
will see the evidences of pain as clearly as you would 
in the expression of man. 

Think of the sickness you have seen among animals. 
The cat or dog with a " sick stomach " — before they 
have made an effort at vomiting you have jumped for 
the door to let them out. In ordinary ailments the 
drooping head, ears and tail, the expressionless eyes 
and face, and indeed the entire want of muscular ex- 
pression, tells the story of impairment of life. Tako 



STUDY OF DIAGNOSIS. 51 

an irritative disease, of the intestines for instance, and 
the marked contraction of muscular tissue; the rough 
ened coat, the strong drawn lines of the face, the re- 
tracted lips, tell you the kind of wrong. 

Would you know if your horse was sick by his ex* 
pression ? I think you would, and if the subject had a 
little stud}' you would know the kind of sickness a? 
well. If you found him in the morning with dropping 
ears and tail, expressionless e} r es and nose, you would 
hardly take him out for a day's ride. You recognize 
the expression of exhaustion from over-work, and fee] 
so much for your companion that the stable is visited 
before retiring', and you probably know from his pos- 
ture and expression in the stall whether he is resting, 
or in a condition that precludes rest. 

If in driving you notice the ears drooping or turned 
backward continuously, you know there is something 
wrong. That the one means a wrong of exhaustion, 
and the other a wrong of irritation. If you notice his 
tail fall helplessly between his legs, you feel sure he is 
in no condition for work, is suffering from exhaustion. 
Suppose you observe an unnatural twist in his tail to 
-one side, and you are quite as sure he is sick, the dis- 
ease one of irritation, probably colic. 

Carry this observation a little further, and watch the 
process of labor in animals, and you will be still more 
surprised at the wonderful mechanism of voiceless ex- 
pression. You will be able to read the history as plainly 
as if expressed in language. The process of dilatation, 
the expulsive second stage, the tedious and difficult 
labor, the irregular and inefficient uterine contractions, 
the rigid soft parts, etc. Let us watch the case of a 
cow with puerperal fever, (yes, she has puerperal fever, 



52 STUDY OF DIAGNOSIS. 

and other puerperal diseases as has the human mother), 
and you will see every phase of suffering, and see it so 
distinctly that you can not forget it if you would. 

You notice a horse put out one of his feet in stand- 
ing, and at once you think of disease. By the exj)res- 
sion of the leg and its position, } T our accomplished 
horseman will locate the wrong for you ; telling you 
whether it is in the shoulder, leg. knee, in the lower 
articulations, or in the hoof. How does he tell? Be- 
cause the leg has a language, and he has learned it. 

I have cited these examples as subjects of thought. 
This study requires thought, and the doctor is so little 
in the habit of right thinking with reference to human 
disease and diagnosis, and so certain that everything 
must be known, that it is better to get a basis for 
thought outside. If the reader recognizes the truth of 
these statements, and can confirm them by observation, 
he will say at once — " if disease is thus clearly ex- 
pressed in the lower animals, there must be similar ex- 
pressions in man, and the subject is well worth my 
attention.'' Disease has a voiceless language, and it is 
this we wish to study, but in order to do so successfully, 
the reader must get a basis for thought, commence to 
think of it, and find his illustrations in every-day life. 

It is well to have clearly before us at the commence- 
ment, the objects of the examination, and the facts that 
may be determined ; they may be classified as follows : 
1st. The right life that we designate as health; 2d. The 
wrong of life that we call disease — the amount of vital 
impairment; 3d. The condition of rest ; 4th. The con- 
dition of unrest; 5th. Disease of excitation ; 6th, Dis- 
ease of depression ; 7th. Pain ; 8th. The evidence of 
local disease, both as to structures involved, and kind. 



STUDY OF DIAGNOSIS. 53 

Decumbence. — In acute disease, the impairment of 
life is usually such that the patient assumes and keeps 
a horizontal position, as this requires the expenditure of 
much less power than any other. We use the term de- 
cumbence in preference to the old medical one, decubi- 
tus, and it is defined. by Worcester as " The act, or the 
posture of lying down, prostration." In health the de- 
cumbent position is associated with the idea of rest, 
and when assumed at unusual times, with the idea of 
debility. Thus the first idea obtained from seeing the 
patient in bed is, that there is impairment of life. It 
would be a blessing to the sick if the physician could 
get this fact so thoroughly impressed, that he would re- 
fuse to depress the life still more by the administration 
of drags. 

Evidently this fact is one of much importance, and 
whilst the general expression may not be absolute evi- 
dence, it is among the best we have. If in acute dis- 
ease the patient keeps his bed all the time, there is con- 
siderable impairment of life. If in ordinary chronic 
disease we find the patient frequently assuming the de- 
cumbent position, and maintaining it for a considerable 
time, we have to consider it an evidence of enfeeble- 
ment, and we husband our patient's strength, and em- 
ploy the class of remedies known as restorative, with 
appropriate food. 

Studying the patient's expression in bed, we find that 
it gives us additional information. If he lie on his 
sides, changes his position readily, holds his shoulders 
and extremities in position, we conclude that the im- 
pairment is not great as yet. But if we see him in- 
clined to lie upon the back, or if upon the side that the 
shoulder falls forward or down, the arm falls and is 



54 STUDY OF DIAGNOSIS. 

expressionless, the upper leg and hip show the inclina- 
tion to fall, and even the soft tissues of the face droop, 
we are certain there is great impairment of life, and the 
treatment must be conservative and restorative. In the 
worst case, where the patient lies continuously upon his 
back, and is inclined to slip toward the foot of the bed, 
physicians usually recognize the approach of death. 

There can be no mistake about the importance of the 
inquiry, or the character and certaint}^ of these expres- 
sions. If we know that the life is feeble, we will care- 
ful 1}^ husband it, and guard against unnecessary expen- 
diture. If we know the life is feeble, we will be sure 
to avoid unpleasant and harsh medicines, especially the 
class antiphlogistic. If we know the life is feeble, we 
will appreciate the importance of keeping the digestive 
organs in good condition, and giving the ; necessary 
food. If we know the life is feeble, and we have anjr- 
thingin our Materia Medica that willaid and strengthen 
it, we will realize the imj^ortance of its use. 

To determine the condition of rest or unrest is of 
great importance. When a man or a part is sick, rest 
is necessary to recovery, and very much of the treat- 
ment used looks to procuring rest. The j)Osition of de- 
cumbence is assumed to get rest, yet we find that many 
times it is not sufficient. It is well to know that we 
have to think of this with reference to sleep as when 
awake, for though sleep usually means rest in health, it 
may not give rest in disease. 

It is well to get an idea of perfect rest in health, as a 
standard of comparison. Observe the child sleeping, 
and the perfect equipoise of the entire muscular system, 
and the natural position of the extremities show the 
condition of rest. Even when the child falls asleep in 



STUDY OF DIAGNOSIS. 55 

a constrained and unnatural position, the body so 
adapts itself to it, that we have the idea of rest. A 
group of harvest workmen, taking their noonday rest 
on the grass under the shade of a tree, will give every 
shade of this restful expression, and is well worth our 
study. We learn something here that can not be told 
in words, but which serves as an excellent standard of 
comparison at the sick bed. Notice the position of a 
healthy person in sleep, especially bow the body accom- 
modates itself to bed and pillows, so that one position 
will sometimes be maintained the whole night, with 
rest to every part. 

Now when we come to examine the sick, the condi- 
tion of unrest is clearly expressed. The body does not 
accommodate itself to the bed, and the effort to main- 
tain the position shows itself in the constraint of dif- 
ferent parts. We see it in the evident contraction of 
the cervical muscles to hold the head in position ; in 
the unnatural flexure of the extremities to maintain the 
body and themselves in position. We have every 
gradation of these expressions, from that which comes 
some time after the position of the body has been 
moved, when the patient is tired, to that which is so 
continuously marked, that we know the patient has not 
one moment's rest. 

The position of the body also tells us something with 
reference to the fifth and sixth propositions — whether 
the disease is one of excitation or depression, especially 
as regards the circulation. This also is an important 
element in diagnosis, and refers us to appropriate reme- 
dies. 

TJ e condition of excitation is marked by constraint 
and indue contraction. We notice it in the expression 



56 STUDY OE DIAGNOSIS. 

of the entire person, and of special parts. In the first 
it has reference to the entire body, in the second it is 
more the expression of local disease. The ideas that 
we get is of want of ease, and of constant effort on the 
part of the muscular system to obtain it. An unusual 
and constrained position of one or more of the extremi- 
ties is quite a common expression. It may be but 
flexure of one leg, throwing it out or from the body, or 
a contraction and elevation of one shoulder, or a prone 
fore-arm and hand with marked muscular contraction, 
or an unpleasant constrained position of the head, with 
prominence of the cervical muscles, or we may have it 
in facial expression. Once the mind is directed to it, 
these features are quickly learned, and having the 
knowledge of health, Ave quickly determine the extent 
of the lesion. 

The evidences of enfeebled function — depression, are 
just the opposite. Whilst in the previous case, we have 
an unusual excitement of the nerves, and of the vascu- 
lar systems, in this we have deficient innervation, and 
impaired circulation. In this there is want of expres- 
sion, the body lies, so to speak, as if no effort were made 
to hold it in position ; parts fall of their own weight. 
This want of expression is noticed especially in the 
subcutaneous muscles, and in the skin, giving an un- 
pleasant uniformity of surface, and a sodden expression 
to the soft tissues. 

Pain, or suffering, is expressed in every portion of 
the body, and one may learn to recognize it as soon as 
the eyes strike the body, and yet it would be difficult 
to describe the expression. When pain is associated 
with, or the result of undue excitation, the expression 
will be that just named under this head. But if asso 



STUDY OF DIAGNOSIS. 5? 

ciated with, or the result of an enfeebled condition, 
either of the entire body, the part suffering, or the 
brain, the general expression may be quite the reverse, 
and will more resemble the exhaustion that follows ex- 
cessive grief — one of anguish. 

As has been clearly shown by Darwin,* expression is 
most marked in those muscles in most common use, or 
those associated with mental activity. Thus we would 



*I have now described, to the best of my ability, the chief ex- 
pressive actions in man, and in some few of the lower animals. 
I have also attempted to explain the origin or development of 
these actions through the three principles given in the first chap- 
ter. The first of these principles is, that movements which are 
serviceable in gratifying some desire, or in relieving some sensa- 
tion, if often repeated, become so habitual that they are per- 
formed, whether or not of any service, whenever the same desire 
or sensation is felt, even in a very weak degree. 

Our second principle is that of antithesis. The habit of volun- 
tarily performing opposite movements under opposite impulses 
has "become firmly established in us by the practice of our whole 
lives. Hence, if certain actions have been regularly performed, 
in accordance with our first principle, under a certain frame of 
mind, there will be a strong and involuntary tendency to the 
performance of directly opposite actions, whether or not these 
are of any use, under the excitement of an opposite frame of 
mind. 

Our third principle is the direct action of the excited nervous 
system on the body, independently of the will, and independently, 
in large part, of habit. Experience shows that nerve-force is 
generated and set free whenever the cerebro-spinal system is ex- 
cited. The direction which this nerve-force follows is necessarily 
determined by the lines of connection between the nerve-cells, 
with each other and with various parts of the body. But the 
direction is likewise much influenced by habit; inasmuch as 
nerve-force passes readily along accustomed channels. 



58 STUDY OF DIAGNOSIS. 

expect to' find the most marked expression in the face, 
and next probably in the hands and the extremities. 
If the reader will think for a moment, he will probably 
recall distinct expressions in these forms. He will 
especially recollect the common expressions of pain in 
the muscles of the orbits and frontal region from con- 
traction of the corrugator supercilii, some of the fibres 
of the occipito frontalis, the orbiculars, and sometimes 
the zygomatic. His attention will only need be called 
to the forced contraction of the flexors of the hand 
during labor, the involuntary expression of pain, and 
to similar contraction in the feet. Indeed here is a 
most excellent study, and one may learn the natural 
history of pain by closely observing a few labors. 

There is nothing like having a familiar example for 
study, and we may look still further at the phenomena 
of childbirth. I need hardly say that these expressions 
have the same meaning as in ordinary disease, though 
here we find them greatly intensified. Possibly we will 
get as good an idea of rest during the absence of pain 
in a natural labor, as we can get anywhere. And in a 
difficult labor we will get as distinct an idea of the state 
of unrest. We observe the pain finding expression in 
marked muscular contraction of the muscles of the 
upper and lower extremities and the forced flexion of 
the muscles of the hands and feet. We also see the ex- 
pression of pain in the countenance, but in natural 
labors it is evanescent and not very marked. In diffi- 
cult labors. especiall} T where the pains are inefficient, we 
find the constant contraction of the " muscles of pain," 
and it is one of the evidences of this condition. 

The evidence of local disease will be found in the po- 
sition of the body with reference to removing pressure 



STUDY OF DIAGNOSIS. 59 

from the part, or giving it support. This is sometimes 
so distinct that the attention is at once directed to the 
affected part. If the position of the body is such as to 
take off muscular pressure, we conclude that the disease 
is one of excitation. If, on the contrary, the position is 
such as to give additional support, we would think of 
it as being one of impaired innervation and circulation, 
possibly congestion. A man gives a diseased leg rest 
in the same manner as a horse. Flexion takes off ten- 
sion, and if the disease is one of irritation, the limb is 
flexed. Disease of bladder or rectum will be indicated 
by flexure and crossing of one thigh over the other. 
Disease of the abdominal viscera, by flexion of the 
thighs upon the trunk and probably flexion of the trunk. 
Disease of one kidney will be announced by flexion of 
the body on the affected side. Disease of stomach by 
marked flexion of the trunk, and relaxation of the ab- 
dominal muscles and diaphragm, and thoracic respira- 
tion. Disease of one lung will be indicated by the 
flexion of the body on the affected side, and the droop- 
ing of that shoulder. Disease of the upper lobe of the 
lungs will be indicated by the falling of the shoulders 
forward, the additional curvature in the upper dorsal 
and cervical spine, and by abdominal respiration. 

A very natural expression of disease is the involun- 
tary movement of the hand to it. In typhoid fever, 
when the patient is seemingly wholly unconscious, we 
find the hand over the bladder in retention of urine, as 
it seeks the umbilicus when disease of Peyer's patches 
is marked. The child suffering from disease of the 
ear involuntarily carries the hand to the affected part. 
In acute disease of the kidneys the hands are carried to 
the loins. In some gastro -intestinal disease the hands 



60 STUDY OF DIAGNOSIS. 

sometimes go to the mouth, and it seems as if the child 
wanted to get something out of its throat, It is always 
well in low forms of disease to carefully watch these 
expressions, as they give us early intimations of local 
trouble. And in diseases of children, when we have to 
depend almost wholly upon our own observation, it is 
also well to carefully observe every expression. 

Facial Expression. — The fact has already been no- 
ticed that mental states find easiest expression in the 
usual channels of innervation, and through those mus- 
cles in common use. This is not only true of mental 
activity, but is also true of disease. There is no disease 
without a wrong of the nervous system, and I think I 
may add with truth, that there is no wrong of life that 
is not represented upon the surface through the nervous 
system. We may not be able to read it, because our 
senses have not been trained to observation, and we 
have not sufficient experience, but the fact that disease 
is thus expressed should stimulate to study. 

The face will show clearl}^ the right life that we call 
health ; and the wrong life we call disease. If one will 
closely study the expression of the face in health, and 
compare it with the expression seen in sickness, this 
fact will be clearly seen. It not only tells us of im- 
paired life, but also of the kind of impairment, and of 
the remedies that will remove the wrong, and restore 
health. It will be well to make this study with refer- 
ence to — 1st. The condition of the brain ; 2d. With 
reference to the condition of the sympathetic nervous 
system, and associated spimil cord; 3d. With reference 
to the condition of the circulation and the blood ; 4th. 
With reference to local disease; 5th. With reference to 
pain ; 6th. ^Resistance of disease. 



STUDY OF DIAGNOSIS. 61 

The Condition of the Brain is very clearly ex- 
pressed in the face, and we have learned quite a good 
deal of its language. We may subdivide this study 
into — a. With reference to the circulation, determination 
of blood, congestion, inflammation, effusion ; 6. The nu- 
trition of the brain ; c. Its functional activity. 

Determination of Blood is marked by flushed faco, 
bright eyes, contracted pupils, and general but moderate 
contraction of the facial muscles. The expression is 
one of excitation, and the patient is restless and uneasy. 

The direct remedy is GJ-elseminum. The indirect 
means are those which relieve vascular excitement, and 
the old-fashioned derivatives — counter-irritation, etc.* 

Congestion is marked by dull eyes, dilated pupils, 
immobile pupils, expressionless face, patient dull, in- 
clined to sleep, and eventually coma. 



• *A bright and sparkling eye is as characteristic of a pleased or 
amused state of mind, as is the retraction of the corners of the 
mouth and upper lip with the wrinkles thus produced. Even the 
eyes of microcephalous idiots, who are so degraded that they 
never learn to speak, brighten slightly when they are pleased. 
Under extreme laughter the eyes are too much suffused with tears 
to sparkle; but the moisture squeezed out of the glands during 
moderate laughter or smiling may aid in giving them lustre; 
though this mast be of altogether subordinate importance, as they 
become dull from grief, though they are then often moist. Their 
brightness seems to be chiefly due to their tenseness, owing to the 
contraction of the orbicular muscles and to the pressure of the 
raised cheeks. But, according to Dr. Piderit, who has discussed 
this point more fully than any other writer, the tenseness may be 
largely attributed to the eyeballs becoming filled with blood and 
other fluids, from the acceleration of the circulation, consequent 
on the excitement of pleasure. He remarks on the contrast in 
tho appearance of the eyes of a hectic patient with a rapid cir- 



62 STUDY OF DIAGNOSIS. 

The direct remedy is Belladonna. In some cases, 
and when associated with local disease with impairment 
of the involuntary muscles, Ergot. The indirect means 
are counter-irritation, dry or wet cupping, stimulant 
cathartics. 

An intermediate hypercemia, observed in apoplectic 
conditions is marked by fullness of eyes, which are 
protruded, fullness of face, prominent veins, and from 
contraction of the platysma a drawing down of the face 
and angles of the mouth. 

For this condition the direct remedies would be 
Ergot, Lobelia in stimulant doses, Apocynum. The in 
direct remedies, dry or wet cupping, stimulant hydra 
gogue cathartics. 

Inflammation is marked by still greater contraction 
of the muscles, especially those of the orbits and the 
frontal region, the deeper flushing of the face, the 
sharper expression of the eyes, which are dry and 
pinched, the contracted pupils, and as the life is im- 
paired, by the appearance of constriction of all the tis- 
sues around the base of the brain. 

The direct remedies in the first stage of an inflamma- 
tion of the brain are : The proper sedatives, Aconite or 
Veratrum, and Gelseminum. These may be followed 
and aided by such as increase the action from skin, kid- 
neys and bowels. The indirect remedies are such as 
may call the excitation to other parts. 

dilation, and of a man suffering from cholera with almost all the 
fluids of his body drained from him. &ny cause which lowers 
the circulation deadens the eye. I remember seeing a man 
utterly prostrated by prolonged and severe exertion during a 
very hot day, and a bystander compared his eyes to those of a 
boiled codfish. — Darwin. 



STUDY OF DIAGNOSIS. 63 

Effusion is marked by the dullness, and finally by 
coma. The eyes lose their sharp, bright expression and 
become dull; the muscles of the lower part of the face 
relax, as do the muscles that move the inferior maxillary 
and the mastoid. If the irritation still continues, the 
contraction of the orbiculars and frontal muscles per- 
sists, and the evident constriction or pinched appearance 
around the base of the brain becomes more prominent. 
If the irritation passes away with the effusion, these 
muscles gradually lose their power, and the upper part 
of the face assumes a dull, sodden appearance. 

The direct remedies are small doses of Acorn le and 
Belladonna, alternated with Apocynum. The indirect 
means will consist in cupping the spine, and the use of 
a stimulant hydragogue cathartic. 

The Nutrition of the brain is not so easily deter- 
mined, yet I think we may reach correct conclusions in 
the majority of cases. The enfeebled nutrition will be 
marked by a want of expression, especially in the mouth, 
showing a want of decision. The eyes may have a 
normal appearance at first sight, yet as we watch them 
uncertainty is shown in their movements. In some 
cases, the expression when the patient's attention is not 
attracted, is very like that which follows exhaustion 
from excessive emotion. 

Softening of the Brain, so called, will be marked 
by a smooth, placid countenance, the want of expres- 
sion in the forehead being especially marked. In some 
of these cases the tissues have their ordinary fullness, 
and sometimes the soft tissues of the face are unusually 
full, yet they look soft and flabby, and hang in un- 
natural folds. 

Atrophic Irritation of the Brain is marked by 



64 STUDY OF DIAGNOSIS. 

the pinched and uneasy expression of the upper facial 
muscles, the muscles of the orbits and the frontal region. 
The patient holds his head in a constrained position, 
frequently inclined to one shoulder, and the face turned 
to one side, giving the eyes an unpleasant expression of 
obliquity. The elevation of one eyebrow and the fall- 
ing of the other, with an apparent divergence in the 
axis of the eyes, will locate the lesion in or near the 
cerebellum. 

The evidences of structural disease vary with the situ- 
ation and character of the lesion. They may be 
divided into irritative and atonic, the one showing 
marked contraction of some muscle or muscles of ex- 
pression, the other a want of contraction, and conse- 
quent fullness and drooping. Sometimes in the severest 
structural disease there is no external expression. 

The Functional Activity is very clearly shown in 
facial expression, and we will observe the entire range 
from normal function to furious delirium on the one 
hand, and to entire loss of function and conscious life 
on the other. 

Activity is not only shown in muscular contraction, 
but in alternate contraction — the play of the emotions — 
of the muscles. This change of expression is one of 
the most familiar examples of mental activity. In de- 
lirium we observe that the play of the muscles is exag- 
gerated, as indeed is the expression of all the emotions. 
This is especially noticeable in the expression and 
movement of the eyes, and their external muscles. 

Want of Activity is expressed by want of contrac- 
tion of the facial muscles ; dull, immobile eyes, and full 
lids. 

The condition of the sympathetic nervous system is 



STUDY OF DIAGNOSIS. 65 

pretty clearly shown by the eyes, the orbital muscles, 
anid the tissues about the base of the brain. The disease 
of irritation is shown by the contraction of the tissues 
which form the bed of the eye, the retraction of the 
eye, especially upward, the thinned and constricted 
eyelids, and the tissues about the temples. In some 
cases the pinched or contracted alee nasi is a marked 
feature. The disease of atony is shown b}^ the full, ex- 
pressionless eyes, fullness of the lids, pallid and waving 
alse nasi, and fullness and want of expression about 
the month. 

A temporary want of sympathetic innervation that is 
rectified b}^ Podophyllin, is shown in the fullness of all 
the tissues of the face, especially the upper portion, and 
by fullness of the veins. 

For the disease of irritation, I prefer Aconite, Bhus, 
Brj^onia, Muriatic Acid, Nitric Acid, the selection being 
made by the other symptoms present. Temporary re- 
lief is obtained by the local application of Chloroform 
before and behind the ears, and over the first cervical 
ganglion. The Chloroform is so applied as to prevent 
evaporation, and a change in the pulse will usually be 
noticed in a few minutes from its first application, and 
the relief is marked, and very frequently it lasts for 
some time. 

The disease of atony is met by Nux, Phosphorus, 
Quinine, stimulant doses of Lobelia, minute doses of 
Podophyllin, Digitalis, more rarely Veratrum, the bitter 
tonics and food. 

Whilst the expression of the face will give us pretty 

accurate information with regard to the circulation, we 

may obtain this information more directly elsewhere. 

If the cellular tissue is full, we think of Veratrum. If 

6 



DO STUDY OF DIAGNOSIS. 

it is shrunken, Aconite. If the expression of the eyes 
and associate muscles is dull, with fullness, we think of 
capillary congestion, and Belladonna. If the cellular 
tissue is full, the face expressionless, and the veins 
prominent, Podophyllin. If the eyelids are especially 
full, Apocynum. If the eyes have a pinched expres- 
sion, dry in acute disease, secretion of tears in absence 
of fever, dry, shriveled epidermis, flushed left cheek, 
Ehus Toxicodendron. Eight eyebrow drawn down, and 
expression of eye changed, flushed right cheek, Bryonia. 
These are the most prominent examples, and in each 
case there is a wrong of the circulation, which may be 
the predominant wrong. At any rate, the remedies 
thus indicated will prove curative. 

With reference to the condition of the blood, we may 
find more direct expressions than in the face, yet these 
are not unimportant. The sodden tissue evidences 
poor blood and poor nutrition, as the firm elastic tissues 
show good blood and good nutrition. The typhoid con- 
dition of the blood will be clearly shown in the con- 
tracted and opaque skin in the one case, and the sodden 
inelastic tissues in the other. P3'88mia will show itself 
first, in the marked contraction of tissue about the base 
of the brain, sinking in of the bed of the eyes, and espe- 
cially by retraction in the upper part of the orbit. 

Some local diseases are clearly indicated by facial ex- 
pression. Disease of the respiratory apparatus will be 
shown by the expression of the nose and accessory 
muscles. The lesions of irritation by contraction, the 
lesions of atony by relaxation. Any one who has 
watched the progress of an acute inflammation of lungs, 
of pleura, of bronchia, with irritative cough, must have 
seen the pinched expression of the nose, and the con- 



STUDY OF DIAGNOSIS. 67 

traction of the alse. So marked is this, that sometimes 
it seems to precede the trouble, and will be marked, be- 
fore the disease of the respiratory apparatus has full 
development. The relaxed and waving alee nasi gives 
an unj)leasant impression of disease, and as before 
named, has reference to the lesion of innervation, as 
well as to impairment of the respiratory function. 

The expressions of the mouth are associated with dis- 
ease of the abdominal and pelvic viscera. Let us take 
the familiar examples of intestinal worms as an illus- 
tration. The full upper lip, with pallor, the white lines 
around the mouth, and picking the nose, is the most 
pronounced evidence of ascaris lumbricoides This 
worm inhabits the small intestine, and the conditions 
present are atony of mucous membranes, with impaired 
function, and increased secretion of mucus, and at once 
we think of the associated symptoms and the intestinal 
wrong. 

The remedies will be those which will give normal 
stimulation to the structures involved, Podopl^llin, 
Santonine, some of the ordinary cathartics, the sto- 
machic bitters, and sometimes the alkaline salts, or 
acids, as may be indicated by other symptoms. 

If fullness in this case means atony and impaired 
function, and increased mucous secretion, it must mean 
it always, and we will always think of such remedies 
as will influence the small intestine and associate viscera, 
giving normal stimulation and circulation, and restoring 
functional activity. There is a peculiar expressionless 
mouth, or an expression of " loss of spirits," with a little 
depression of the angles of the mouth, that invariably 
means Kux Vomica. 

Nausea is shown by depression of the angles of the 



68 STUDY OF DIAGNOSIS. 

mouth, and slight incurving of the lower lip. If the 
tissues are full, we know that there is atony ; if pinched 
and shrunken, that there is irritation and determination 
of blood. 

It is a singular fact, and one not heretofore noticed, 
so far as my reading extends, that simulation of these 
expressions will provoke sensations in the parts referred 
to. The instance just given affords a marked example. 
Let a person draw down the angles of the mouth and 
incurve the lip, and he will be quite certain to feel 
nausea after a time. In two persons who tried it the 
sense of nausea was very marked ; in one producing 
vomiting, in the other an arrest of digestion and head- 
ache. Try to simulate the frontal expression of pain, 
and it will be singular if you do not wake up unpleasant 
sensations somewhere, perhaps real pain. 

Contraction of the orbicularis oris is usually found in 
some diseases of the reproductive organs, especially of 
the female. In chronic disease, there is distinct retrac- 
tion from the other muscles of the face, and the entire 
tissues seem thinned. In some of these cases the zygo- 
matic muscles are also prominent. 

Pain and Suffering are distinctly expressed in the 
features, yet not always in the same way. Firm con- 
traction of muscles is the most common expression. 
Thus every reader will recollect the contracted brow as 
evidencing pain, especially pain with irritation of the 
nerve centres. We involuntarily associate contraction 
of the structures about the eyes, and the wrinkled skin, 
with pain, or with suffering But we have the evidence 
of pain in this region without muscular contraction ; 
indeed there is the reverse, drooping of the tissues, the 
expression is sad, of the exhaustion that follows exces- 



STUDY OF DIAGNOSIS 69 

sive grief, and we are assured that there is enfeebled 
circulation in the brain, and the pain is the expression 
of atony. 

It is very important to make these distinctions in 
order to select remedies. Pain is the result of two very 
opposite conditions — an excited circulation and an en- 
feebled circulation. In the one case we use Gelsemi- 
num, the sedatives, salines, Bhus, Macrotys, Bryonia, 
as may be indicated. In the other we use Quinine, 
stimulant doses of Opium, Nux, stimulants, tonics, 
beef tea or other histogenetic food. 

Pain in the abdomen, pelvis, or lower extremities, 
finds expression in the mouth. Acute pain almost 
always finds expression in contraction of the mouth ; 
when very severe the lips are firmly drawn in, the 
angles of the mouth retracted, and somewhat depressed. 
In some other cases, the angles of the mouth are drawn 
in, and there is that action of the muscles of the upper 
lip that gives it and the cheeks a full expression. 

I hardly need call attention to the fact, that some 
patients resist disease by an influence of the will, and 
that sometimes this effort is very important. Others 
yield to it from the first, and thus favor its progress. 
Every one has made these observations, and will recog- 
nize the importance of knowing whether a patient re- 
sists or yields, as it may determine whether he will re- 
cover or die. 

Darwin remarks that — " The firm closure of the 
mouth tends to give an expression of determination or 
decision to the countenance. No determined man 
probably ever had an habitually gaping mouth. Hence, 
also, a small and weak lower jaw, which seems to indi- 
cate that the mouth is not habitual!}^ and firmly closed, 



70 STUDY OF DIAGNOSIS. 

is commonly thought to be characteristic of feebleness 
of character. A prolonged effort of body or mind im- 
plies previous determination ; and if it can be shown 
that the mouth is generally closed with firmness before 
and during a great and continued exertion of the mus- 
cular system, then, through the principle of association, 
the mouth would almost certainly be closed as soon as 
any determined resolution was taken." 

I do not think any one can make a mistake here, and 
certainly it is important to know whether the patient is 
inclined to resist disease, and is determined to get well, 
or whether he is yielding, despondent, hopeless. The 
firm mouth means that the patient will get well if he 
can. The relaxed, drooping mouth, falling jaw, trem- 
bling muscles, show us the need of giving the patient 
courage, and strengthening the will power. It also 
shows the necessity of increased care to conserve vital- 
ity, and of the employment of restorative remedies. 

Expression in Motion. — We not only find disease 
expressed in position, and in persistent muscular con- 
traction, as heretofore named, but it is also shown in 
motion. We see a man standing or sitting, and ob- 
serve that his soft tissues seem to sit on him like a 
badly fitting suit of clothes, and we think at once of 
impaired nutrition and degeneration of tissue. But it 
may be only a want of innervation, from habitual 
torpor of the nervous system. Set him in motion, and 
we will soon see whether this is so or not, for there are 
none so sluggish in this respect, but what they may be 
aroused. 

We notice the movements of the person that we may 
confirm the diagnosis of expression, especially as re- 



STUDY OF DIAGNOSIS. 71 

gards the important point of undue irritation and cir- 
culation, or impaired innervation and circulation. 
The quick, restless movement is characteristic of the 
first. The desire to lie still, and the slow movements, 
of the second. Possibly there is no evidence of disease 
more definite than this, and it should be allowed its full 
weight in diagnosis. 

In some cases the rapid movement is but a means of 
removing excessive excitement of the brain and spinal 
cord, as in great grief or joy, or in case of severe, but 
temporary pain. In such cases it may be looked upon 
as a means of relief, for if the excessive emotions, or 
pain were pent up, the person might suffer severely 
from it. 

But in other cases, whilst it tells of nervous irrita- 
bility, the bodily movements give no relief, but even in- 
tensify the wrong, besides causing exhaustion. In 
these cases we endeavor to get bodily rest from the 
first, as a means of allaying the nervous excitation. 
Every one will have noticed the influence of the phy- 
sician, nurse, or friend, who with kindness but firm- 
ness, insists on keeping still. The hand placed upon 
the body of the sufferer to give support, seems to 
strengthen the will power, and frequently with an effort 
on the part of the patient comes rest and relief. 

There is a case of restlessness from an enfeebled and 
atonic condition of the nerve centres that requires 
notice. The unsteady movement, or the evidence of 
exhaustion following it, with the anxious, depressed 
countenance, tells the story. In the other case we will 
find almost continued tension of the muscular system. 

Whilst in the case of irritation and determination of 
blood, we would employ the sedatives, with Gelscminum, 



72 STUDY OF DIAGNOSIS 

or remedies exerting a like influence, in that of atony, 
we would use Quinine, Nux, Phosphorus, stimulants, 
tonics, and histogenetic food — beef-tea. 

Increased movement is not associated with structural, 
or even with severe local functional disease, so that un- 
less it points to a wrong of the cerebro-spinal centers 
we do not regard it as an unpleasant symptom. In or- 
dinary colic the patient is restless, and seems to get re- 
lief from motion, but in the severer forms of colic, 
called "bilious," and in acute enteritis, he remains 
very still. 

In local disease the patient favors the affected part in 
movement. Frequently the first evidence we have of 
morbus coxarius, is the care shown in moving the leg 
and placing the feet in walking, and the elevation of 
the hip to remove pressure from the joint. Turning 
the toes inwards, both in movement and rest, has the 
same signification. One can readily distinguish a wrong 
of the pelvic viscera by the movement of the hips and 
extremities, showing the constant effort to prevent 
stress or pressure of the parts. This will be noticed in 
some uterine disease (irritative) as well as in displace- 
ments. In chronic disease of the kidneys, a forward 
curvature of the spine is frequently marked, and the 
patient is observed to put the hands upon the hips in 
rising from the chair, and sometimes in walking. If 
but one kidney is involved, or the liver, or spleen, we 
observe the slight flexure to one side, and the effort to 
save the part from the movement of muscles. Evi- 
dently the drawing forward of the shoulders — " winged 
scapula," is a symptom of similar import so far as the 
lungs or thoracic region is concerned. So certain is 
thJs, that with the marked falling forward of the 



STUDY OF DIAGNOSIS. 73 

shoulders, and separation of the scapulae, one may be 
sure there is some disease in the thorax. The head 
drooped forward has a similar import, though this is 
sometimes an indication of a wrong of the sympathetic 
nervous system. 

In irritative disease of the cerebrum, or of the organs 
of special sense the head is flexed, but in disease of the 
medulla oblongata, cerebellum, pons and crura, the 
head is drawn backwards. Forced extension, or head 
drawn backward, will be recollected as a prominent 
symptom in cerebro-spinal meningitis. 

In all these cases flexion and favoring the part in 
muscular movement are evidences of irritative disease, 
and indicate the treatment. First, remedies that influ- 
ence the affected part; and second, remedies that re- 
move excited innervation and circulation or functional 
activity. 

In another class of cases, we will find flexion from or 
opposite the affected part, and the position of the body, 
and muscular motion is such as to give support and 
moderate pressure. The evidence in this case is of im- 
paired circulation, congestion, effusion, and enlarge- 
ment. It is safe to say that in the majority of these 
cases the remedies will be such as will give additional 
stimulus. 

If one will closely observe the movements of the ab- 
dominal muscles, they may determine conditions of dis- 
ease in pelvis or abdomen. The careful, slight move- 
ment evidences disease of the pelvic viscera if especially 
marked below — the chylopoietic viscera, if especially 
marked above. The full abdominal walls, with slug- 
gish movement, evidences atonic disease and congestion. 

If we examine with reference to the thorax, we will 
7 



74 STUDY OF DIAGNOSIS. 

find that free movement of the abdominal muscles and 
diaphragm, and but slight movement of the upper 
thorax, is evidence of disease of the upper lobes of the 
lungs. On the contrary, thoracic respiration, with but 
slight and careful movement of the abdominal muscles, 
evidences disease of stomach or liver. 

We have already examined the expression of the face 
sufficiently, and the movements of the muscles do not 
give much additional evidence. Twitching of the 
muscles is an unpleasant expression, and indicates un- 
due spinal irritation, or irritation of the basilar brain, 
the cause being frequently extrinsic. If of the mouth, 
our attention is directed to the abdominal organs ; if of 
the upper lip and face, to the stomach ; if of the nose, to 
the lungs ; and if of the eyes and forehead to the brain 
and spinal cord. 

The quick, involuntary movement of the eyes, refers 
us at once to the excito-motor nervous system, and at 
once we make an examination to determine the source 
of the lesion, its cause, and adopt means to prevent 
its further progress, and convulsions. The forced con- 
traction of one of the muscles of the eyeballs, turning 
them upwards, downwards, to one side, or causing stra- 
bismus, evidences disease of the brain, which may or 
may not be associated with wrong of the spinal cord. 
The character of the disease may be determined by the 
expression of the eyes and associate muscles, or by 
other symptoms. 

In diseases of children we will notice that sudden 
contraction of muscles and movement of parts is a pre- 
cursor of convulsions. The quick movement of the 
hand, with contraction of the fingers, the quick move- 
oient of the lower extremities, with forced flexion, or 



STUDY OP DIAGNOSIS. 75 

the quick movement of the head upon the pillow, or 
the sharp, jerking movement of the shoulder, should 
never be neglected. 

This is but a mere outline of the subject, yet if it 
stimulates to observation, pointing out the way, it will 
serve its purpose. It is something one must learn from 
observation, and not simply store up in the memory. 
Indeed, unless the senses can be trained with the 
memory of facts, but little benefit will follow. 



COLOE OF THE SUEFACE. 

As has already been named, the education of the eyes 
to distinguish colors, is of much importance in diag- 
nosis ; and the reasons will be obvious to the reader. 
There is no property of living bodies so sensitive as 
color. It is usually thought of as evanescent, change- 
able, fleeting, and the expressions of poetry in this re- 
gard, but represents the results of close observation. 

The florist is guided by it to a very considerable ex- 
tent. When he visits his green-houses in the morning, 
his eye closely scans the plants with reference to their 
health. Change of color, even so slight that it would 
not be noticed by an ordinary observer, is to him evi- 
dence of disease. He recognizes in change of color, 
the escape of gases from his flues, want of ventilation, 
a wrong in the temperature, the want of, or a wrong 
plant food, the presence of parasites, etc. He not only 
makes his " diagnosis " from change of color, but gives 
the prognosis as well. 

The farmer, without any special training, or knowing 
why, recognizes the wrong color in his plants, and 



76 STUDY OF DIAGNOSIS. 

speaks of their sickly appearance. If he has been a 
close observer, there is a something about their expres- 
sion, and usual]}' in their color, that tells him of the 
character of the wrong — from drouth, from wet, from 
too much heat, from cold, from atmospheric changes, 
from want of plant food, from excess of certain foods, 
or from a wrong kind. He recognizes the coming of 
blight, rust, mildew, and the various parasitic diseases, 
by these changes., before the diseases are fully de- 
veloped. 

These are familiar examples, and should prompt to 
diligent study on our part. For, if in the vegetable 
world, disease may be recognized in changes of color, 
should it not be a means of diagnosis in animals and 
man ? And if so definite in determining the kind of 
disease in vegetable life, will it not be equal!}' definite 
in determining disease in man? It will be noticed 
further that color has reference to the life ; to the life of 
the blood, to the nutrition of tissue, to the oxygenation 
and decarbonization of the blood, and to the waste and 
excretion. 

Even here the popular expression should have stimu- 
lated professional inquiry — he ha3 a healthy color — ■ 
what is the color of health ? he has a sickly appearance, 
what is a sickly color? If the popular mind recognizes 
health in color, and disease in color, is it not well that 
we should make a careful study of it ? 

Color in man has two sources — a. from the blood ; b, 
from pigment — and it is well to distinguish these. In 
the first case the changes of color are referred to wrongs 
of the blood ; in the second they are referred to changes 
in the quantity or character of the pigmentary matter 
of the body. A simple division would be into — a, color 



STUDY OF DIAGNOSIS. 77 

which has red for a basis ; b, color which lacks red, is 
a shade of yellow, brown, black. 

In making examinations with reference to the blood, 
we select parts where the circulation is free and the 
epidermis or epithelium is thin — where the skin is thin, 
and the mucous membranes delicate. We examine the 
nails, the lips, the cheeks, the hands, sometimes the 
feet, the tongue, and mucous membranes of the mouth. 

What is the color of health as shown from the blood ? 
It is rosy, a light shade of carmine and lake, and is 
clear, transparent, and offers no darkness, or admixture 
with blue, purple, or brown. As the finger is pressed 
upon the surface, or pressed over it, toward the heart, 
the rosy color is removed, leaving the structures clear 
and transparent, and the color comes back quickly when 
the pressure ceases. It is difficult to describe color 
in words, but if the reader will now make his examina- 
tions of health he may readily learn to distinguish the 
color of health. 

The shade of rose color in mucous membranes differs 
somewhat from the skin, because it is modified to some 
extent by the pigment in the rete-mucosum. It is well 
to get a clear idea of it by examinations of the lips, the 
tongue, the mucous membranes of the mouth, and 
fauces. The color of mucous membranes is quite 
changeable to a slight degree, even in health, having 
shades of blue, violet, white, probably from the secre- 
tions of the mouth, and the food and drink ; and we 
never regard these slight variations as diagnostic. 

The pigment color of health varies in different races, 
and in different individuals. But if we say it is some- 
what transparent and clean, we may express its char- 
acter for all races. If we take a negro for example, we 



78 STUDY OF DIAGNOSIS. 

will find the jetty black has a transparency and clean- 
ness — glossy and smooth, which will bo readily recog- 
nized. Let this man become sick, and the color grows 
dingy and opaque. If we take the olive or brown 
skin, the same cleanness and clearness of color is 
marked, and it seems so transparent that you may 
almost look into the skin. If you take the Caucassian, 
the brunette will show the same clearness in the skin 
pigment, and in the healthy blonde it seems as if you 
could look quite through the skin, it is so transparent. 
We may even notice these peculiarities in the color of 
the hair, as it shows health and disease like other parts, 
but modified more by local conditions. 

In studying color, especially that given by the pres- 
ence of blood, it is well to note that it may be changed 
in quantit}^ (so to speak), and in kind. Change in 
quantity has reference to an increased circulation, and 
an increased amount of blood in the capillaries; change 
in kind, to the condition of the blood. 

Simple excess may be noticed from any cause increas- 
ing the circulation to the surface, or to a part. We ob- 
serve this excess of color in slight acute diseases, where 
the activity of the heart is increased, and there is gen- 
eral vascular excitement. It is not an unpleasant 
symptom, and points clearly to the arterial sedatives, 
Aconite and Yeratrum, as the special remedies. 

If a part of the surface shows this excess, we at once 
think of its relation to internal organs and functions 
If of the upper portion of the face and eyes, we refer 
the wrong to the brain. If of the cheeks, one or both, 
we refer it to the respiratory organs or apparatus of 
circulation. If of the mouth and lower part of the face, 
we refer it to the abdominal viscera. 



STUDY OF DIAGNOSIS. 79 

As the excess refers to vascular excitement, and 
means general sedatives, so these local excesses mean 
local vascular excitement and local sedatives if we have 
them. Thus for tli3 brain it would mean G-elseminum ; 
for the thoracic organs, Yeratrum ; for the abdominal 
viscera, Aconite, Ipecac, etc. 

It is well to note the condition of the capillaries in 
this examination, and we may determine somewhat of 
their condition by the effects of pressure. If the capil- 
laries are in normal condition, pressure should efface 
the redness, but it is but momentary. If the finger is 
drawn across the reddened surface we notice the white 
line made by displacing the blood, but it rapidly passes 
away, and the blood flows quickly in and fills the ves- 
sels. If now we examine the redness in scarlet fever 
in the same way, we will find that the fingers carried 
over the part with pressure, effaces the redness, and 
leaves a distinct white line, more or less persistent, as 
the fever is severe. 

This shows enfeeblement of the capillary circulation, 
especially from the arterial side, and is an indication for 
Belladonna. In the larger number of cases, Aconite" is 
the arterial sedative. The next best remedy to Bella 
donna is the Carbonate or Hydrochlorate of Ammonia. 

If the capillary wrong is from venous obstruction, 
the color will be deeper, and the wrong will be asso- 
ciated with fullness of cellular tissue in many cases, 
and the white line made by pressure is not so clear. 
In this case, Podophyllin, Lobelia, Bryonia, are reme- 
dies. 

We not only find an excess, as above named, but in 
other cases a defect in color, showing poor blood, leuco- 
cythfiemia, or an impaired circulation to the surface. The 



80 STUDY OF DIAGNOSIS. 

pallor of anaemia is shown in all parts of the body, and 
is associated with evidence of impaired nutrition. In 
the rare pathological condition, leucocytlisemia, there is 
sometimes marked pallor, but usually it is disguised by 
increase or change in the pigment of the skin. In de- 
ficient circulation to the surface, we have want of color, 
but no evidence of want of blood in totality, or impaired 
nutrition. 

Deepening of color — dark red — is usually associated 
with zymosis, and has reference to sepsis of the blood. 
It is associated with asthenia, and when observed it 
tells of impaired function But it especially shows the 
need of acids, and in this respect refers to a direct 
remedy. It makes no difference where we find it most 
marked, its meaning is quite the same, of course modi- 
fied to some extent by local disease. 

If the reader will think for a moment of the cases he 
has seen presenting deep redness of the surface, he 
will recognize the truth of these statements. In typhus 
fever, the gravity of the disease is shown by the flushed 
skin — dark-red. If in smallpox, we find the skin 
assuming this dark-red color, we are confident the dis- 
ease will be severe, showing dejjravation of the blood, 
and marked asthenia. If we observe it in measles, we 
anticipate trouble from tardy apj)earance of the erup- 
tion, depravation of the blood, respiratory trouble, and 
impairment of function. If seen in pneumonia, it talks 
to us of approaching " typhoid symptoms," of a low 
grade of inflammation, and great prostration. So clear 
is the evidence, and so rare the exceptions, that it be- 
comes one of the most reliable evidences of disease we 
possess. 

The meaning is modified to a certain extent by the 



STUDY OP DIAGNOSIS. 81 

results of pressure — whether the color is solid and un- 
yielding as the finger is pressed over the surface— or 
whether it is effaced by such pressure as heretofore 
named in simple excess. In the first case it has refer- 
ence wholly to the lesion of the blood, in the other iu 
part to the lesion of circulation — at least the evidence 
is less grave. 

If the dark redness is an evidence of zymosis — sepsis 
— it speaks directly of antiseptics as a necessary part of 
the treatment. It says clearly — this patient must be 
kept clean, his clothing and the bed-clothing must be 
frequently changed, and kept clean and sweet, all the 
surroundings must be clean, he must have good air, fre- 
quently changed by good ventilation. It means further, 
that proper means shall be employed for disinfection 
when this becomes necessary. 

If the dark -redness is associated with asthenia and 
impairment of life, and gives us timely warning of such 
impairment, it will caution us against the use of all de- 
pressant remedies, or anything that will impair any of 
the important functions of the body. And it suggests 
the necessity of keeping the stomach in condition to 
recerve food, and the proper selection and preparation 
of food during the progress of the disease. 

But it directly refers to acids as remedies, and this is 
of much importance. Acids here are the antiseptics 
and antizymotics. We give Muriatic Acid, Acetic 
Acid in the form of good cider, and Lactic Acid in the 
form of whey, and we find the condition of the patient 
markedly improved. Muriatic Acid is especially the 
antiseptic, though the others have an influence in this 
direction. 

The dull purple (bluish) of venous blood has reference 



82 STUDY OP DIAGNOSIS. 

to imperfect venous circulation, and imperfect decarbon- 
ization of the blood. It may be caused by disease of 
heart or lungs ; if not we recognize a lesion of sympa- 
thetic and associate spinal nervous systems. It evi- 
dences an unpleasant condition of life, and one that 
should be removed if possible. In some cases the dull- 
ness of color becomes so marked, that we designate it 
as leaden. 

If we find local structural disease to account for it, 
this will receive our attention. If it is sudden, and 
associated with prsecordial oppression and constriction 
of the chest, Lobelia is the remedy. If less markedand 
chronic, we will think of Cactus, Digitalis and Pulsa- 
tilla. In acute cases, Chloroform counter-irritation 
around the lower margin of the thorax, gives speedy 
and marked relief. 

In the lesion of cholera we will find the blueness of 
hands and feet dependent upon enfeebled capillary cir- 
culation, the blood being loaded with carbonic acid 
gas. If the condition of the blood can be so changed, 
as to enable it to circulate, this passes off. This blue- 
ness with pallor is one of the most marked indications 
for common salt as a medicine. 

Want of color, with a shade of solid blue where the 
blood shows freely as under the nails, the lips, the 
cheeks, and thin skinned portions of the body, may be 
assumed to indicate the want of Iron. 

A violet tint with increase of redness uniformly, or 
only where the circulation is superficial, is a prominent 
indication for Nitric Acid. 

Deep color, with purplish, brown, or black tinge, is a 
prominent indication for Baptisia 

Color not deep, but muddy or dirty, of parts freely 



STUDY OF DIAGNOSIS. 83 

supplied with blood, is an indication for Sulphurous 
Acid. If there is this dirty shade with pallor, we would 
use Sulphite of Soda. 

When we come to study the local changes of color 
referred to the blood, we divide them into two classes, 
the one in which the change is to be referred to a lesion 
of some other part — sympathetic ; the other in which 
it is dependent upon local disease. The reader will 
notice that the significance of color must depend very 
much upon this, for whilst the one may have no refer- 
ence to the condition of the blood at large, or to any 
structural lesion, the other is wholly referred to the 
lesion of the structures, and to changes in the blood. 

AVe always want familiar examples to show that a 
method of *study is likely to prove advantageous — that 
is a basis of fact, and we will adduce the three familiar 
cases of — change in the color of areola of the nipple, 
the dark line under the eyes in certain conditions of 
women, and the white line around the mouth in some 
intestinal diseases of children. 

Every practitioner will have noticed the darkened 
areola of the nipple as an evidence of pregnancy, but 
may not have had his attention called to it as an evi- 
dence of disease of the reproductive function. In 
wrongs of this function simulating spermatorrhoea, we 
will find this change of color marked, as we will in 
scanty menstruation with congestion, and in hyper- 
trophy of the cervix uteri. Of course we do not look 
for this, except in the diagnosis of pregnancy, but in 
this case it is one of the most valuable symptoms. 

If you should notice the deep color under or around 
the eyes in women, you would say at once there was a 
wrong of the reproductive organs or function, and you 



84 STUDY OF DIAGNOSIS. 

would rarely make a mistake. If the tissues seemed 
diy, the e} T elids sunken and contracted, it would be 
safe to say that the disease was one of irritation, and 
would probably be relieved by Pulsatilla and Macrotys, 
(especially if functional.) And if the eyelids were 
full, swollen, relaxed, that the disease was of congestion 
or atony, and would be benefited by Hamamelis. Apc- 
cynum, Staphysagria, Phosphorus. Iron, etc. 

Many cases present themselves where we do not wish 
to suggest an examination of the reproductive organs 
at first, or there may be some reason why it should not 
be made at present, hence the importance of other 
means of knowing the character of the wrong, and the 
class of remedies we may select from. 

If one should notice the white line around the mouth, 
with full pallid upper lip, full or contracted mouth, he 
would at once refer the symptom to a wrong of the 
gastro-intestinal apparatus. The reference is undoubt- 
edly right, if we except the rare case in which the 
symptom is dependent upon lesion of the brain. There 
is a wrong of the stomach and bowels. What is the 
character of that wrong ? If the structures are full, it 
is pretty surely one of atony — a want of innervation 
and a sluggish circulation. If the structures are con- 
stricted and pinched, the wrong is very certainly one 
of irritation, excited innervation and circulation. 

Is it worth our while to read the evidences of disease 
in the patient's face? I think it is. especially when the 
remedies are at once suggested. The white line around 
the mouth — gastro-intestinal disease. With fullness of 
tissue — Podophyllin. Hydrastia. Santonine. With con- 
striction and thinning of structures — Aconite, Ipecac. 

But suppose we notice a peculiar bluish or leaden 



STUDY OF DIAGNOSIS. 85 

tint to this white line around the mouth, and see a 
slight dragging clown of the corners, we would recog- 
nize the gastro-intestinal lesion — remedy, Bismuth, or 
sometimes minute doses of Arsenic. 

Increased color of cheeks has been noticed as a symp- 
tom of thoracic disease for thousands of years. What 
relation has this flushing of cheek to the condition of 
the lungs ? Can you explain the nervous and vascular 
connections ? Evidently we can not tell why, and I 
doubt if the evidence would be any more valuable if we 
could tell why. This is one of many examples that the 
interrogatory — why ? is not alwaj^s a profitable study 
in medicine. 

We know the fact, that a habitual recurring flush 
of one or both cheeks has reference to an irritable or 
diseased lung. The persistent high color, even though 
it be a distinctly circumscribed spot, has a different 
meaning. If we notice this circumscribed flushing of 
the cheeks, our attention is at once attracted to the re- 
spiratory apparatus. Associated with frequency of 
pulse and increased temperature, it telle us of com- 
mencing tubercular deposit. In this case the one cheek 
is usually flushed. 

It may be remarked further, that this symptom is 
always associated with a wrong of the sympathetic 
nervous system, especially in its relation to circulation 
and nutrition, and in phthisis we only find the bright, 
flushed cheek with irritation. Sometimes there is quite 
as marked pallor, and the evidence would be a want of 
innervation. 

The bright-red flush of left cheek in acute disease is 
usually referred to thoracic disease, but does not always 
indicate it. It evidences a lesion of sympathetic and 



86 STUDY OF DIAGNOSIS. 

sjunal innervation, but is especially valuable as calling 
our attention to -Rhus Toxicodendron as the probable 
remedy. 

The deeper flush of right cheek is more frequently 
seen in disease of serous membranes and fibrous tissues, 
but is especially valuable because it points out Bryonia 
as the probable specific remedy. 

Whilst the bright color of the cheeks, where it has 
reference to disease of the respiratory organs, tells us 
of irritation and activity of circulation, deep color in- 
dicates impairment of the circulation and of the life. 
The livid, purplish color in some cases of angina pec- 
toris, may be taken as the type. We have it in much 
less degree in thoracic aneurism, in apoplexy of lungs, 
and in some very severe cases of asthma with conges- 
tion. The dark redness is always evidence of a difficult 
and imperfect circulation. 

There is a pinkish color of parts freely supplied with 
blood, that is regarded b} 7 some as an unpleasant symp- 
tom. As this color becomes more pronounced, we ob- 
serve ifc in the veins as well. In women we may usually 
refer it to a menstrual wrong, which will be corrected 
by the use of small doses of Pulsatilla. Actea Alba, 
Helonias. For the chronic lesion we think of Phos- 
phorus, the Hypophosphites, the bitter stomachics, and 
food. 

Among the things that old women know is-— that 
prominent Hue veins crossing the nose in children is a 
sign of feeble vitality, and it is quite as true as if a phy- 
sician knew it. There is something wrong in the life 
when you observe these cutaneous veins showing the 
distinct and constant blue line, whether it is across the 
nose, at the wrists, upon the back of the hand, over the 



STUDY OF DIAGNOSIS. 87 

"breast or abdomen, or elsewhere. Whilst it may not 
point oat any special medicine, it does prompt us to ad- 
vise that the child have abundant oat-door exercise, 
good blood-making food, and that it shall not commence 
study early, or be much confined until there is a much 
stronger and robust life. 

Unusual blueness of veins is a very good indication 
for Iron. If associated with pallor of surface, we may 
select Iron by Hydrogen, or Yalett's mass, but if there 
be deep color of tongue, Tincture of Muriate of Iron. 

The color of the conjunctiva and sclerotic will some 
times give us information in regard to the circulation 
of the brain. If we find an injected conjunctiva (not 
the result of local disease), we conclude that the cere- 
bral circulation is similarly affected. If the color is 
bright, and the surface looks smooth and moist, we have 
evidence of determination of blood. If the color is 
deep and the surface looks dull and dingy, or dry and 
2)inched, it represents hyperemia, with obstruction to 
the return of blood — the apoplectic condition. The 
dull, colorless eye is the best indication for Belladonna, 
though we use it when the eye is injected, with tortuous 
vessels. 

In superficial disease, the color of the part is a means 
of determining its condition, If we take the ordinary 
symptoms of inflammation, increased color — redness — is 
one of the first named as constant. Given increased 
color, with heat, pain and swelling, and we say there is 
inflammation ; but which of these will best tell us the 
real condition of the part? I should answer, color. 

If the color is bright, health}^ red, we know at once 
that the inflammation is simple, and is not very likely 
to work a very great wrong to the part, or to the body 



Ob STUDY OF DIAGNOSIS. 

at large. It tells us of irritation, determination of 
blood, and of activity of circulation ; the second part 
of the wrong of circulation — stasis — is in but small pro- 
portion. It says, give general arterial sedatives, use 
local sedatives, get rid of increased heat, and establish 
secretion. The evidence is quite the same, whether we 
are looking directly at the inflamed part, or at some 
distant surface, that is influenced by sympathy. 

If the color is deep -red and dull we are confident 
there is marked impairment of life and arrest of circu- 
lation. The fact that there is too much blood in the 
part is evident, that the capillaries are enfeebled, and 
the circulation in them is sluggish or arrested, that 
change has commenced in the stagnant b'ood, and that 
the life of the part will be destroyed, unless these 
wrongs are corrected. It says distinctly, strengthen 
the general circulation, whilst you lessen its frequency, 
and conserve and sustain the life of the blood by rest 
and food. If a local application is to be made, it is now 
stimulant — we want to -strengthen the life of the part. 
If we select an internal remedy that is to influence the 
part from the blood, this remedy must be stimulant or 
tonic in its character. 

If the part assumes a blue or purplish color we recog- 
nize venous stasis, and an obstruction to the circulation 
from the part. With our attention called to the nature 
of the wrong, we will find its cause and remove it if 
possible. My attention was first called to this evidence 
of venous obstruction in a case of fracture of the fore- 
arm, with laceration of the hand, in which a roller was 
applied before the splints, yet not very tight. Inflam- 
mation sprang up in the hand, and the third day came 
this bluish discoloration, with a great deal of local 



STUDY OF DIAGNOSIS. 89 

trouble. The roller was removed, and the difficulty 
slowly passed away. I have seen the same wrong arise 
from the position of au extremity being such as to im- 
pede the circulation of blood. 

In some cases the wrong being general, venous im- 
pairment is cardiac. We do not know why, but we 
rarely find an impairment of the right heart, when the 
left is sufficient for the systemic circulation. Lobelia in 
stimulant doses exerts a very favorable influence in these 
cases. If there is fullness of cellular tissue, Apocynum 
may be associated with it, or given alone. If the 
wrong is from venous impairment, and is chronic, 
Hamamelis is probably the remedy. 

The erysipelatous redness is so distinctive, that being 
once seen it can hardly be forgotten. The vivid color- 
ation, evident dryness, shining appearance, give the be- 
holder a sense of burning. It makes no difference so. 
far as the significance of this coloration is concerned, 
whether we have the local inflammation of the skin or 
not, it refers us to a lesion of the blood, zymotic in 
character. If the surgeon find this tint of vivid red- 
ness on the edges of a wound, or the flaps of an ampu- 
tation, he would be at once on the alert to get rid of 
the lesion of the blood. If the physician observed this 
erysipelatous flush on the cheek in inflammation of the 
lungs, or any where on the surface during the progress 
of an inflammation or fever, he might feel sure he would 
have a more than usually serious case to manage. 

We may distinguish four shades of this erysipelatous 
redness quite well marked in many cases, pointing out 
the remedies for the disease of the blood, and the local 
inflammation. In the first the redness is quite vivid, 
and the edges of the local disease show a simple erytho- 
8 



90 STUDY OF DIAGNOSIS. 

matous flush, and the part does not look dry and con- 
stricted. Sometimes there is arterial throbbing of the 
part, and the pulse is full. In this case Veratrum is the 
general and topical remedy. In the second case the 
redness is very vivid, and the parts dry and constricted, 
with sometimes the appearance of a slight pustular 
eruption. The pulse is small, sharp, vibratile ; the 
remedy is Rhus Toxicodendron. In the third case the 
redness has a deeper shade, sometimes vivid, sometimes 
dull. The remedy, both general and local, is Tincture 
of Muriate of Iron. The fourth case shows more or 
less of a blanched appearance, as the disease advances : 
sometimes in the centre, sometimes at the borders, 
sometimes of the deep structures — you seem to be look- 
ing through the superficial redness. In these cases the 
general remedy is Sulphite of Soda, the local remedy 
Sulphurous Acid, Permanganate of Potash, or Carbolic 
Acid. 

The variations of pigment color in different individ- 
uals is so great in health, that it might seem almost im- 
possible to get definite information from its variations 
in disease, yet I think we will find it quite as certain 
as other evidences of disease. Of course we must have 
a correct idea of normal pigment coloration, and some 
guide to the natural tint of the individual. Transpa- 
rency and cleanness are the characteristics of health, 
whatever may be the shade. The lesions might be 
divided into those of excess, defect and perversion, 
though the last is the most important. 

Excess of pigment, when it retains the clearness and 
transparency of health, is usually evidence of active 
life, and good nutrition and excretion. Of course out- 
door exposure is always taken into consideration, as 



STUDY OF DIAGNOSIS. 91 

causing an increase of pigment. Local excesses of 
pigment have a variable meaning, though if still clear 
and transparent we think of functional activity. If we 
take the areola of the nipple, the clean, transparent 
deep color evidences healthy gestation, as does the 
deepened color over the gland. The increase of abdom- 
inal pigment has the same meaning, as has the increased 
pigment color of the vulva. Even the increased pig- 
ment of face observed during gestation is an index of 
healthy function. Not so the unequal and unpleasant 
brownish coloration known as morph. 

The deep pigment coloratfon of the neck in brain 
workers is a sign of healthy nutrition of the nerve 
centres, whilst the want of jngment would indicate 
anaemia, and the dirty pigment would show a wrong of 
nutrition. 

The coloration of the skin and hair have the same 
associations. The clear, transparent color is the evi- 
dence of health, especially of the skin. The deepened 
color is evidence of an active life, especial!} 7 of the vege- 
tative functions ; whilst a loss of color is at once re- 
ferred to impaired nutrition. Even the color of the 
hair is subject to slight changes, and one may learn to 
distinguish by this the condition of the nutritive func- 
tions. It is an unpleasant sign to find the hair becom- 
ing dull and sickly in color. 

There is an increase of pigment distinctly brown, 
and in patches on various parts of the body, which is 
known as " liver spots." They generally make their 
appearance on parts covered b} 7 the clothing, and may 
be quite large and extensive. We refer them to a 
wrong of the bile pigment, and frequently find it asso- 
ciated with a wrong of digestion, and impairment of 



92 STUDY OF DIAGNOSI8. 

the function of the brain. The remedy is Podophyllin, 
associated with its natural bitter principle, Bebeerina, 
(Hydrastia). 

The brownish-yellow coloration is evidence of a 
wrong of the organs of digestion. We may find it 
only about the mouth or the face, or we may find it 
pretty general where the lesion is chronic. It refers 
us to Nux Yomica as the remedy. 

Give us the same color, but dull and opaque, or with 
a leaden tinge of adjacent skin, and we again refer it 
to a lesion of the organs of digestion. The remedy is 
Chelidonium ; Podophyllin, if the tissues show more 
than usual fullness. 

The bright yellow of jaundice is a symptom of wrong 
of the liver. What the condition of the liver may be 
other symptoms must decide. But in so far as the 
color is concerned, we expect to wash it out through the 
kidneys. 

There is a peculiar sallowness with a tinge of green 
that indicates great impairment of blood-making and 
nutrition. The remedy is Copper ; we usually give 
Bademacher's Tincture. 

No one could mistake the opaque, tallow-like color 
of hypochondria, and associate states. It tells us of 
impairment of the digestive and blood-making organs, 
of nutrition, and of waste and excretion. There is a 
slow renewal of life, and the tissues are old and feeble. 
Very clearly in this case we want a more active " re- 
newal of life," and we stimulate the processes of retro- 
grade metamorphosis and excretion on the one hand, 
to remove the old structures, and see that the function 
of digestion is well performed, that we may have in- 
creased nutrition. 



STUDY OF DIAGNOSIS. 93 

One could hardly mistake the evidence of the dingy, 
dull, grimy, dirty color of skin. It refers us to a wrong 
of the blood — " bad blood," and we conclude that the 
blood is as dirty as the skin. Of course it would not 
do to mistake the dingy, dirty skin of the " great un- 
washed," but this is not very likely. Soap and water 
will show the difference. In this case remedies to in- 
crease secretion, and sometimes to promote retrograde 
metamorphosis, hold the first place, though we do not 
forget the importance of improved nutrition. 

There is a deepened tint of skin, dull and opaque, 
that is a very good indication for Arsenic or Phos- 
phorus. The tissue seems to have lost life, and is in- 
elastic. Dullness of color and opacity, may be regarded 
as the special features ; and opacity where the color is 
lighter than usual may indicate the remedy. 

If we have a distinct want of pigment, the want of 
color not dependent upon anaemia, or an enfeebled cir- 
culation of blood, we think of Sulphur as a possible re- 
storative. G-iven in small doses, we sometimes find it 
exerting a marked influence upon the nutritive pro- 
cesses. 

EXAMINATION OF THE TONGUE. 

" Let me see your tongue," says the doctor at every 
visit, though what he expects to learn from " seeing 
the tongue " he would be puzzled to tell you, unless it 
was that the patient was " bilious." Of course habitu- 
ally seeing the tongue in disease will, unconsciously, 
many times, grow some knowledge of its diagnostic 
value, and if the physician is a close observer, it will 
give him valuable aid in determining the character of 



94 STUDY OF DIAGNOSIS. 

disease. But many men are so little in the habit of 
using their eyes, and thinking for themselves, that they 
learn but very little. 

If we think for a moment, we will see that the tongue 
may tell us of — a, the condition of the digestive appa- 
ratus ; b, the condition of the blood; c, the condition of 
the nervous system and d, of the functions of nutri- 
tion and excretion. As these are important inquiries, 
indeed just the things Ave want to know, we will make 
the tongue talk as plainly as possible. 

We find the expression of disease in — a, its form;. 6, 
its condition of dryness or moisture ; c, its coatings ; d, 
its color; and e. its motion. It is well to think of the 
subject in this methodical way, even though we are not 
able to follow it wholly in this study. 

The common idea of physicians is, that the tongue 
expresses the condition of the stomach and intestinal 
tract, and it should be examined with reference to this ; 
few think that it may give further information. Being 
a part of the digestive tract, supplied by the same 
nerves, and invested by the same mucous, membrane, 
we would naturally expect it to show something of the 
condition of parts below. 

If we say that its condition may be taken as the type 
of the condition of parts below, we will not be far out 
of the way. True, there are many exceptions, but the 
rule is a very good one, and will hardly lead to serious 
error. The mind at once recognizes the changes of 
form, movement, condition, color, and secretion, as ex- 
pressions of local disease. It will not be far wrong, if 
it recognizes them as expressions of disease of the entire 
digestive apparatus. 

Change of form is quifce expressive, and rarely .leads 



STUDY OF DIAGNOSIS. 95 

us into error. The elongated and pointed tongue ex- 
presses the condition of irritation and determination of 
blood to stomach and intestinal canal very distinctly, 
and it is safe practice to give it full weight, and be very 
careful in the administration of remedies. As it is 
associated with excitation of the nerve centres, this is 
to be taken into consideration, when we value the evi- 
dence with reference to the stomach and bowels. If we 
observe this change of form early in the disease, we not 
only anticipate unpleasant gastric irritation through 
the sickness, and use care in avoiding irritants, but we 
employ means to remove it. Among these maj T be 
named minute doses of Aconite, Ipecac, Hydrocyanic 
Acid, Peach-bark infusion, small doses of Rhubarb, and 
Bismuth. 

The full tongue, broad and thick, is the evidence of 
atony of the digestive tract, especially of the mucous 
membranes. In this case the stomach and intestinal 
canal tolerates the common medicines given, and the 
use of cathartics is less harmful, and may be more bene- 
ficial than in others. 

The pinched, shrunken tongue expresses a want of 
functional activity in the digestive apparatus. It is the 
tongue of advanced acute disease, and is usually asso- 
ciated with dryness. "Want of functional activity" 
hardly expresses the condition, for the life of the diges- 
tive apparatus has suffered to such an extent, that there 
can be but little function. Whilst it is one of the indi- 
cations of want of food, it causes us to be very careful 
in its selection and administration, giving small quan- 
tities at a time, and at such periods as the unpleasant 
symptoms are least marked. 

The fissured tongue in chronic disease points us to 



96 STUDY OF DIAGNOSIS. 

lesion of the kidneys inflammatory in character. In 
some cases the fissures are transverse only, but in severe 
cases they are somewhat irregular, and b} T pressing the 
tongue down it is seen to separate in irregular patches 
of prominent villi. The symptom is so definite, that 
one may be assured of inflammation when this tongue 
presents. 

The fissured tongue in the advanced stage of febrile 
diseases refers us to lesion of the kidneys, or irritation 
of the nerve centres. In many cases we find a wrong 
in the secretion of urine, and close examination shows 
a condition of kidneys bordering on inflammation. It 
deserves careful consideration, and especially means to 
place the skin in better condition, and to allay irrita- 
tion of the cerebro-spinal centres. 

The conditions of dryness and moisture are important 
evidences of the condition of the intestinal tract. If 
the tongue is dry, we are sure the stomach and intes- 
tinal canal can do but little digestive work, and we give 
it as much rest as possible. In such cases food is alwaj^s 
given in fluid form, and usually above the temperature 
of 100°. It is also carefully selected and prepared, 
that the labor of digestion may be as small as possible. 
If the tongue is dry we are confident there is want of 
secretion from the intestinal canal and associate glands, 
and indeed that there is a condition present which will 
prevent the action of direct remedies to favor secretion. 
It is most absurd to emplo} 7 cathartics in such cases, 
unless the object is simply to remove irritant accumula- 
tions. Moisture, on the contrary, expresses a condition 
favorable to functional activity. True, there may be 
impairment of function, as when the tongue is fu41 
showing atony, or heavily coated, showing increased 



STUDY OF DIAGNOSIS. 97 

mucous secretion, or dirty, showing depravation of the 
blood and secretions. 

If in acute disease with dryness of the tongue, we 
observe it becoming moist, we are confident of improve- 
ment, of the establishment of secretion, and indeed of 
all the vegetative processes. Having this meaning, it 
is nearly always regarded as a favorable symptom. 

The coatings of the tongue are observed with care, 
as they are thought to be especially symptomatic of the 
condition of the digestive tract and the " liver."* 



^Appearance of the Tongue as a Symptom of Disorder 
of the Stomach — The aspect of the tongue was held by the 
older writers in medicine to be one of the most important criteria 
of the state of the digestive organs; and its morbid appearances 
were therefore carefully observed and minutely described by 
them as indications for both diagnosis and treatment 

In more recent periods, however, the value of the evidence 
furnished by this organ has been, if not entirely denied, at least 
so greatly depreciated, that it seems desirable to ascertain what 
are the limits of our knowledge with regard to the association of 
changes on its surface w T ith those occurring in lower portions of 
the alimentary canal. 

The question appears to be capable of being resolved into three 
principal divisions : 

1. "What are the nature and causes of the alterations in the 
tongue which have been regarded as diagnostic of affections of 
the stomach ? 

2. In what other diseases, occurring independently of stomach 
affections, are these changes observed ? 

3. What is the nature of the alterations of the digestive organs 
with which these conditions of the tongue have been found to be 
associated ? 

The appearances of the tongue which have been most com- 
monly believed to be associated with the diseases of the rest of 
the intestinal canal, are (a) an increase of its epithelial covering 
9 



98 STUDY OF DIAGNOSIS. 

Whilst there is much of error in the common ideas of 
"furred tongue." something valuable maybe learned. 

The vivid whiteness of the tongue, evidently a change 
in the epithelium, evidences simple functional wrong, 
and is associated with the febrile state. If observed at 
other times, it may be taken as an indication that the 
stomach and digestive tube want rest. 

The thin, transparent mucoid coating of the tongue, 
evidently upon and from the secretions of the mouth, 
evidence enfeebled digestive function, frequently from 
intemperate eating or drinking. 



or "fur." which may present various degrees of thickness, and 
different shades of color; (b) enlargement of its pa pil; (clae) 
various shades and degrees of redness of the mucous membrane; 
and (d) certain alterations in its size and shape. 

(1) The fur or coating (saburra,) has been shown by micro- 
scopic examination to consist of epithelium scales, which are 
often fattily degenerated, and sometimes massed together, of free 
fat drops, and of confervoid growths; of these the largest pro- 
portion is formed of the epithelial cells which are derived from 
the covering of the organ together with the saliva and buccal 
mucus, which in drying form a thick glutinous material, con- 
glomerating the other elements into a mass. 

The fur may be of greater or less thickness, dry or moist, uni- 
form, or accumulated more particularly at the posterior portions* 
it is sometimes deeply fissured by sulci, which may extend into 
the mucous membrane beneath. At other times it may separate 
in flakes from the surface, which then may look raw, and of a 
deeper red than natural, but which may. when the process of 
separation is gradual, present no deviation from the normal 
appearance. 

Mixed with the fur may be sometimes found pigment, blood 
corpuscles, mucous or pus corpuscles, or the remains of vegetable 
and animal portions of food. 



STUDY OF DIAGNOSIS. 99 

The fur which has consistence is evidently upon the 
tongue, and can be scraped off — evidences impairment 
of function, and the wrong is generally in proportion 
to its thickness. If uniformly distributed it may be 
regarded as having reference to the entire intestinal 
tract ; if restricted principally to the base, we think of 
greater wrong of the stomach. The heavily loaded 
tongue would call our attention to accumulations in the 
bowels, and would prompt to means (mild) to secure 
their evacuation. The heavily loaded tongue at the base 
calls attention to accumulations in the stomach, and 

The color may be white or milky, or may present various 
shades of yellow or brown. 

The nature and cause of some of the changes in color are very 
imperfectly understood. Some of them arise from articles of 
food, medicinal substances, tobacco, etc.; a large proportion, how- 
ever, are caused by slight hemorrhages from the gums ; while 
some others, and especially those occurring in fevers, remain un- 
explained. Excepting, however, those cases where there is direct 
pigmentary discoloration from jaundice, when other tissues par- 
ticipate in the change, there is no foundation for the common 
belief that a yellow fur on the tongue has any necessary connec- 
tion with hepatic disorder. 

As regards the chief causes to which the production of this fur 
is attributable, may be mentioned : 

(a) Idiopathic conditions in which the tongue of some persons 
may, consistently with apparently perfect general health, form 
and throw off a much larger amount of epithelial covering than 
is ordinarily the case; inquiry should, therefore, be directed tc 
this point before any general conclusions are formed respecting 
the indications to be drawn from its presence. 

(6) States in which a coating is formed on the tongue by the 
simple drying of inspissated mucus and saliva, owing to the 
mouth being kept open, as is oA>n the case during sleep. 

(c) Conditions of irritation in the mouth itself, giving rise to 



LofC. 



wmm 



100 STUDY OF DIAGNOSIS. 

suggests the use of an emetic to free this viscus, and 
stimulate normal innervation and circulation. 

Yellowness of coating is thought to arise from wrong 
in the hepatic function, and to point to the use of " liver 
remedies." Whilst it may have this reference in some 
eases, it is well to avoid the usual cholagogues. It may 
be said to call for Nux Yomica. small doses of Podo- 
phyllin and Hydrastine. A dull, leaden, yellow fur is 
an indication for Chelidonium. A dull, cheesy look- 



an increased production of epithelium on the cheeks, gums and 
tongue, and which, from their similarity to the state of other 
mucous membranes, where increased secretion, attended with 
shedding of the epithe.ial covering, is the result of irritation or 
subacute inflammatory action, are usually termed catarrhal. 
The belief that this is the true pathology of this state > is also 
favored by the coincidence, in many such cases, either of a gen- 
eral redness of the surface, beneath the thickened epithelium, or 
of hyperemia and enlargement of the papillae, especially of the 
papillae fungiformes of the lateral and anterior portions. In 
some instances, also, the inflammatory state is further evidenced 
by the production of aphthae, giving rise to slight and superficial 
ulcerations, with a reddened base, and often surrounded by a 
reddened margin. 

Many of these conditions of the tongue may, however, be due 
to local causes, such as carious teeth, or other sources of irritation 
to the fifth nerve, or to accumulation of food around the bases 
of the teeth, or to medicinal agents affecting the salivary glands 
and mouth, as Iodide of Potassium and Mercury, or to the habit 
of smoking (though this does not ordinarily produce a thickened 
epithelial fur, nor hyperemia of the papillae fungiformes, its 
effects being generally limited to an enlargement of the papillae 
filiformes, which gives to the surface a finely roughened aspect). 
As smoking, however, is not an unfrequent cause of stomach 
affections, our observations on this head are always attended 
with certain grounds of fallacy. — Fox on Diseases of Stomach. 



STUDY OF DIAGNOSIS. 101 

ing fur, with slight green tinge, is an indication for 
Copper. 

The bright redness of tip and edges, especially of 
papillse is an evidence of irritation with determination 
of blood. It always suggests care in the use of reme- 
dies, rest to the stomach, and the special agents named 
to remove irritation. A good condition, of stomach is 
of first importance in the treatment of disease, and 
when these symptoms present, these means will hold a 
prominent place. 

The tongue gives us the best evidence of the condi- 
tion of the blood, and of the remedies which rectify its 
wrongs. All exudations or secretions from the blood 
must give information of the character of this fluid, 
and there is no better place to observe them than in the 
mouth. The circulation of blood is also very free and 
superficial in the tongue, and we are thus enabled to 
observe its changes of color better than in other situa- 
tions. The reader will recollect the distinction between 
the tongue itself and the fur or coating, when color is 
spoken of, as the one is from the circulating blood, and 
the other from the exudation. 

The broad, pallid tongue — marked want of color in 
the tongue itself — evidences the want of the alkaline 
elements of the body. The evidence is clear and dis- 
tinct, and the want one of much importance. It may 
be the basis of the entirety of the disease, which will 
fade away as soon as the proper alkali is given, or it 
may be but a. portion of the wrong, and the alkaline 
salt prepares the way and facilitates the action of other 
remedies. 

If there is no special indication for some other, we 
prescribe Soda because ii? is the salt of the blood. 



102 STUDY OF DIAGNOSIS. 

Usually we direct the bicarbonate added to water to 
make a pleasant drink, and given freely as the patient 
wishes it. If there is predominant wrong of the mus- 
cular system, we ma}- select a salt of Potash. If of the 
cellular tissue, a salt of Lime. 

The deep red tongue, (usually contracted and dry) 
evidences the want of an acid, as well as that condition 
of the blood known as '■ typhoid." Here, as in the 
preceding case, the want of an acid (undue alkalinity 
of blood), ma}' be the principal element of disease, and 
all the symptoms are ameliorated, and the patient con- 
valesces when it is given. In other cases it is but a por- 
tion of the disease, and the acid facilitates the action 
of other remedies. It is a very common symptom in 
typhoid and typhus fevers, and the use of an acid in 
these cases has been found a very successful treatment 
by Chambers, Anstie and others in the London Hospi- 
tals. Our Prof. King, some twenty-five years since, 
suggested the use of good sharp cider in these cases, 
and it has been employed with much success. He did 
not say there was deep redness of mucous membranes, 
but he might have said so. for he did name the dry and 
contracted tongue with dark sordes, and they are asso- 
ciated together. 

In this case we select with reference to the condition 
of the stomach, and the blood poisoning, and some- 
times we may defer to the taste of the patient. Muri- 
atic Acid usually receives the preference, as it is well 
borne by the stomach, is a natural acid, and is a power- 
ful antiseptic. It is added to water to make a pleasant 
acid drink, and given ad libitum. In some cases sharp 
cider is better borne by the stomach, is grateful to the 
taste, and the small amount of alcobol in it is beneficial. 



STUDY OP DIAGNOSIS. 103 

In others lactic acid, in the form of whey, answers an 
excellent purpose, as it furnishes a calorifacient food as 
Well, 

The deep red, or deep violet colored mucous mem- 
branes, with fullness, evidences sepsis, and is an indica- 
tion for the special remedy, Baptisia. The acid should 
also be given in some cases. 

The full color, with violet shade, superficial and trans- 
parent, is the indication for Nitric Acid, and it will be 
found one of the most valuable remedies of the Materia 
Medica. 

The tongue large, thick in centre, with incurved 
edges, and of a dull blue, or leaden color, is one of the 
strongest indications for Arsenic, and it will rarely fail 
to arrest the progress of disease in such cases. 

The same dull, leaden color, with no change in size 
or shape of the tongue, is one of the best indications 
for the use of Phosphorus, or the H/vpophosphites. 

The slick, raw-beef tongue, the papillae wholly effaced, 
evidences sepsis of the blood, and is one of the most 
marked of the " typhoid " symptoms. The color of 
the tongue is usually deep, and Ave will employ an Acid 
or Baptisia. 

The exudation or fur upon the tongue is a pretty 
good index of the condition of the blood. Of course 
we must weigh the influence of local disease of the 
mouth and teeth, and the sympathetic relations with 
the stomach and bowels, as heretofore named. (See 
note.) 

The dirty fur is an indication of sepsis of the blood, 
as well as of depravation of the secretions. It is fre- 
quently associated with moisture, and the redness is 
rarely increased. We use the common word " dirty," 



104 STUDY OF DIAGNOSIS. 

because it expresses our meaning clearly — the impres- 
sion upon the senses is that of dirt, and its meaning is 
dirt. It may be a dirty- white, a dirty-gray, a dirty- 
yellow, or a dirty-brown, but the dirty, grimy appear- 
ance always assumes prominence in the mind. 

If we have a dirty tongue, pallid, we usually think 
of Sulphite of Soda. If the redness is natural, we may 
use Sulphurous Acid or Sulphite of Magnesia. If dirty, 
with increased redness. Muriatic Acid. 

All shades of brown and black have reference to the' 
condition known as typhoid. We have every shade of 
color from the slight tinge of brown to the deep brown 
or almost black. It is not only the coating of the 
tongue that shows this color, but accumulations of 
sordes about the teeth, and sometimes crusts upon the 
lips. As is the deepness of color, so is the wrong known 
as " sepsis," and so is the need of the class of reme- 
dies known as " antiseptic." As is the deepness of 
color, so is the impairment of life, and the need of care 
and rest to conserve it, and of food and restoratives to 
support it. 

These dark coatings are so usually associated with 
deep redness, that we usually think of acid remedies, 
first of which is Muriatic Acid. But some of the cases 
will need Baptisia, others Chlorate of Potash, and some 
will be benefited by Carbolic Acid. Cleanliness is of 
especial importance in these cases, as all decomposing 
animal matter in the air or surroundings, increases the 
wrong of the blood. 

The reader may not have thought that the tongue 
could tell him much with regard to the condition of 
the nervous system, and yet a little study will show 
that it does give very important evidence. It has 



STUDY OF DIAGNOSIS. 105 

special reference to the condition of the sympathetic 
nervous system, and this may be regarded as the most 
important, but we also learn much of cerebro-spinal in- 
nervation. 

We associate dryness of tongue with excitation of the 
nerve centres, especially the ganglionic. So positive is 
the evidence that it is not possible to mistake it. Dry- 
ness of tongue is associated with vascular excitement, 
and with arrest of secretion from this cause. If in 
acute disease with dryness of tongue, we find it becom- 
ing moist, we know that the nerve centres are being re- 
lieved, and that the circulation is improved, and secre- 
tion is commencing. If in a case of disease marked by 
enfeebled innervation from the sympathetic, and moist, 
relaxed tongue, the tongue commences to dry and be- 
comes firmer, we know that this nervous system has 
been stimulated, and many times it is a first evidence 
of amendment. 

Whilst dryness always evidences undue excitement 
of the nerve centres, and calls for sedatives, or that 
class of agents which remove this, too much moisture and 
relaxation is evidence of the opposite condition. The 
reader will recollect the typical salivation from Mercury, 
and its influence in this regard, and will weigh the de- 
pressant influence of the mineral upon the sympathetic 
nervous system, by these conditions. If after mercu- 
rial salivation, the nerve centres are stimulated by 
Quinine, or Quinine and Opium with Ipecac, the tongue 
will become firmer and may become dry, and if not too 
great, this has been regarded as a good symptom 
Moisture of tongue is one of the prominent conditions 
assuring us of the kindly action of Quinine, and even 
of Opium when indicated. Lf marked, and accompanied 



106 STUDY OF DIAGNOSIS. 

by full, relaxed tissues, the patient always requires 
nerve stimulants. 

Contraction is always an evidence of an excited nervous 
system. Sometimes, indeed, we may measure the 
wrong of innervation by this symptom, as in typhoid 
and typhus fevers, and in the later stages of acute dis- 
ease. The reader who has seen the great nervous 
wrongs of these affections, will recollect the pinched, 
contracted tongue as one of the prominent symptoms. 

Fullness of tongue has the opposite meaning. If 
marked, we are quite sure that innervation is impaired 
from atony, or want of normal stimulus of the nerve 
centres, especially of the sympathetic. It suggests 
nerve stimulants as a part of the treatment, Podophyl- 
lin and Lobelia for the solar and cardiac plexus, Nux 
Vomica, Strychnia, Belladonna, Ergot, for the associate 
sympathetic and spinal nervous sj^stems, and Quinine 
for the associate wrong of the three, or simply for the 
brain alone. 

Whilst the elongated and pointed tongue has especial 
reference to the stomach and intestinal canal, it is one 
of the expressions of disease of the base of the brain. 
It is well to note this fact, for we may have the wrong 
of the brain as the primary lesion, the nausea and vom- 
iting being but the result, and if treatment was wholly 
directed to the stomach, we would make a great mis- 
take. Grelseminum assumes a prominent place here, 
associated either with Yeratrum or Aconite. Rest is 
obtained by the topical action of Chloroform about the 
ear. 

The small tongue, full in the centre, which is covered 
with a thick, tenacious mucoid coat, is an indication of 
marked disturbance of the brain, unless we have evi- 



STUDY OF DIAGNOSIS. 107 

dence "Of acute disease of ears, the globes of the eyes, 
or the sphenoidal or ethmoidal cells. It may indicate 
a very grave lesion, or in the latter case will pass away 
with the local disease. In those cases where the coat- 
ing is removed, the surface is left slick, and very dark 
colored. 

The tongue covered with a grayish or yellowish fur, 
showing small patches of red distributed uniformly 
over the surface, is the tongue of scarlet fever. The 
same appearance will be seen in other cases, where the 
capillary circulation of the skin is enfeebled. 

The eroded appearance of the papillae at the tip of 
the tongue, looking like small, rose-colored bubbles, 
evidences a peculiar wrong of the nerve centres and of 
the blood, for which Rhus Toxicodendron is the 
remedy. 

The movements of the tongue are sometimes of im- 
portance in determining the condition of the brain. If 
the patient has complete command over it, we conclude 
that the functions of the brain are still well performed. 
But if it is protruded with difficulty, is tremulous, or is 
inclined constantly to one side, we are confident we 
have a proportionate cerebral lesion. Whilst we might 
get the evidence elsewhere, it is quite as well to give 
weight to these symptoms, and when observed, to adopt 
means early for the relief of 'the brain. 

From what has been said, the reader will draw the 
conclusion that impairment of nutrition and secretion 
will be indicated by marked drvness and contraction 
on the one hand; or increased moisture and relaxation 
on the other. In the first case there is undue excita- 
tion, and if we select remedies to increase secretion or 
excretion, they will be of a sedative character. In the 



108 STUDY OF DIAGNOSIS. 

other case there is a want of innervation, and the reme- 
dies will be those which will give stimulus and tone. 

There is a sodden, unpleasant looking tongue, which 
is quite as good evidence of cacoplastic material in the 
blood as any we can find. We recognize at once the 
evidence of enfeeblement of the digestive functions, 
and if there is local irritation we expect that the exu- 
date will be of this character, readily breaking down 
and destroying the tissues. 



EXAMINATION OF THE DISCHAKGES. 

The examination of the discharges in common dis- 
eases is usually quite superficial, and whilst it has some 
diagnostic value is usually of little importance. The 
physician from force of habit asks after the discharge 
of urine and feces. Has the patient passed urine? 
freely? was it high colored, or what was its color? 
Has the patient's bowels been moved ? how often ? 
These are the common questions, and the answers are 
very uncertain and indefinite. Possibly the physician 
wishes to examine " the vessel," but in these days he 
is usually satisfied with these casual inquiries, and pre- 
fers to get his information from pleasanter sources. In 
the olden time examination of " the vessel " was of 
greater importance, for the principal part of the phy- 
sician's business was to fill it — medicine meant dis- 
charges. 

It may be well to give this subject a brief study, 
though we do not attach such great importance to it. 
We may divide the study into five parts — a, with refer- 
ence to the discharge from nose and mouth ; 6, with 



STUDY OF DIAGNOSIS. 109 

reference to the discharges from the skin ; c, with refer- 
ence to the discharges from the urinary apparatus ; d, 
with reference to the discharges from the bowels ; and 
e, with reference to the discharges from the reproduc- 
tive organs. 

From the .N"ose. — The discharges from the nose are 
of local significance, and indicate changes of function 
and structure in these cavities. In measles and typhus, 
catarrhal symptoms are among the most prominent, 
and in the first are almost pathognomonic ; but these 
and epidemic influenza are the only instances where the 
disease is referred to the blood. 

The thin, glairy secretion is evidence of irritation 
and determination of blood. The white of egg looking 
mucus of active inflammation. The yellowish, glairy 
discharge of commencing suppuration — muco-pus, and 
the opaque, yellowish, non-tenacious secretion, of the 
subsidence of inflammatoiy action. 

Dryness of the anterior nares is usually referred to 
scanty or arrested lachrymal secretion ; too much mois- 
ture of the anterior nares, thin, watery, to increased 
lachrymal secretion. 

In chronic disease of the nasal cavities, the condition 
of the parts is pretty clearly shown by the character 
of the discharges which have the entire range of mucus, 
muco-pus and pus. In determining the diagnostic 
value of these discharges, we will be guided by the same 
rules as in other situations. "We wish to know the phy- 
sical properties of normal mucus, and of- normal pus, 
and we will then have a standard of comparison; this 
we will study in discharges from the respiratory tract 
below. 



110 STUDY OF DIAGNOSIS. 

From the Mouth. — The discbarges from the mouth 
proper are of saliva with some mucus secretion. But 
through the mouth we have all the discharges from the 
respiratory tract below, of mucus, pus, blood, exudative 
material, etc. We also have occasionally discharges 
from the digestive tract, the stomach, upper small intes- 
tine, and secretion from the liver. 

The saliva normally is a thin, transparent slightly 
viscid fluid, with a marked alkaline reaction to litmus 
paper. If it loses these properties in degree, or is in- 
creased, we will conclude that the first act of digestion 
is improperly performed. Physicians have not been 
properly impressed with the importance of buccal diges- 
tion, and frequently direct their remedies to the stomach 
when it is not at fault. 

We have already seen that dryness of the mouth evi- 
denced arrest of secretion, and necessarily impairment 
of the digestive process. If the salivary secretion is 
found to be scanty, we anticipate a wrong of digestion, 
especially of starchy foods, and a wrong of nutrition. 
It is usually associated with excitation of the nerve 
centres, and local disease presents unusual irritation. 
We have the same results where the saliva is constantly- 
thrown off in chewing and smoking. 

The remedies suggested in chronic disease by scanty 
secretion of saliva are, Iris Versicolor, Phytolacca, 
Panax, and some others of this class, with the Iodides 
and Bromides, especially of Ammonium. 

Increased secretion of saliva is found as a symptom in 
some forms cf chronic; disease, and occasionally in 
acute disease. If marked, it interferes with digestion, 
and is a cause of depravation of the blood. This may 
seem singular to the reader, and yet I think any one 



STUDY OF DIAGNOSIS. Ill 

who has closely observed cases presenting this symptom 
will bear me out. The tendency is always to low 
grades of albuminoid deposits — cacoplastic, or aplastic. 

In acute disease the remedies will be the Alkaline 
Sulphites or Sulphurous Acid, or sometimes Chlorate 
of Potash, or Chloride of Sodium. Quinine and Nux 
Vomica are thought of for the wrong of innervation, 
and Hydrastis and Podophyllin for the wrongs of the 
intestinal canal. The same remedies will be applicable 
in chronic disease, and in addition we may think of 
Phosphorus, Sulphur, and sometimes Arsenic. 

It is hardly worth while to speak of changes in the 
character of saliva as regards its viscosity, as it is always 
associated with excess in quantity, and the indications 
for remedies will be as above. I would call attention, 
however, to the need of antiseptics in these cases, for 
very surely we will have sepsis as a prominent feature in 
the progress of acute disease. If the j>roper antiseptic 
is selected, as elsewhere described, whether Sulphite of 
Soda, Sulphurous Acid, Chlorate of Potash, Baptisia, or 
Muriatic Acid, this symptom will pass away. 

The reaction of the secretions of the mouth to test 
paper will be found to vary, and this will sometimes in- 
dicate the class of remedies to be selected The .alka- 
linity may be markedly increased, and acids will be as- 
sociated with remedies to influence the digestive pro- 
cess. In such a case, with dyspepsia, Muriatic or Lactic 
Acid, largely diluted, with the addition of a small por- 
tion of Nux, will cure when the ordinary means have 
failed. In infantile dyspepsia, we sometimes find the 
saliva neutral, or in rare cases the entire secretions of 
the mouth are slightlv acid. We find the same condi- 
tions in the adult, though not so often nor so marked. 



112 STUDY OP DIAGNOSIS. 

in such cases we would give Phosphate of Soda, and 
surely expect the patient to amend rapidly. 

From the Stomach. — Ejections from the stomach as 
the result of disease may sometimes give valuable in- 
formation, though usually we dejDend more upon what 
the patient tells us than upon what we see. But as a 
matter of interest we may examine the discharges. 

Eructations in d} T spepsia are very acid or feebly acid. 
The first is very common and is usually met by an 
alkali or Bismuth, though experience shows that this is 
not good treatment, or at least but a part of good treat- 
ment. It is associated with hyperesthesia, demanding 
Aconite, Hydrocyanic Acid, Ehubarb, Ipecac, and like 
remedies; with externally the wet pack, either of water 
or water with an acid. The second evidences a condi- 
tion of atony, and suggests Muriatic and Lactic Acids, 
with Hydrastis and similar bitters, Podoph} T llin, etc. 

Eructations containing a yellowish, or yellowish- 
brown coloring material, and of a bitter taste, shows 
irritation of the upper small intestine, and sometimes 
an irritation of the entire chylopoietic apj)aratus. The 
remedies will be such as prove sedative to these parts. 

Blood in the discharges has a variable significance. 
If in small quantities, during violent vomiting, we may 
conclude that some minr.te vessels have given away; if 
dark colored and clotted, we conclude there is passive 
hemorrhage — usually from congestion, except in the 
rare case of ulceration, with erosion of some of the 
vessels, when the discharge may either be of bright or 
clotted blood. 

Yomiting of considerable quantities of mucus is occa- 
sionally noticed in persistent atonic dyspepsia, and its 



STUDY OF DIAGNOSIS. 1 13 

therapeutic value will be obvious. Vomiting of pus is 
at once referred to ulceration, the result of chronic in- 
flammation. 

The " black vomit " of yellow fever, and some rare 
cases of congestive, intermittent and remittent fevers, 
shows the breaking down of the blood, as well as the 
congestion of the digestive mucous surfaces. 

From the Eespiratory Tract. — The discharges from 
the respiratory tract are of mucus, pus, blood, and the 
material of exudation. As heretofore remarked, we 
wish to have a clear idea of the origin and value of 
these discharges, and senses trained to recognize them 
when seen. In health the respiratory mucous mem- 
brane is continuously lubricated with mucus, but it is 
not in quantity to be discharged by mouth ; even the 
increase of quantity is evidence of disease. 

If mucus is thin, glairy, and very tenacious, we know 
that it comes from a mucous membrane in a condition 
of great vascular excitement — inflammation. The more 
marked these proporties, the more active the excite- 
ment. We see it in minor degree in catarrhal bron- 
chitis, but most marked in sthenic bronchitis when 
secretion is first established. The t} 7 pical remedy is 
Yeratrum. 

The opaque mucus, not so tenacious, is associated 
with a subsidence of the inflammation and resolution. 
The quantity maybe such as to enfeeble the part or the 
patient, but other than this it is regarded as a favor- 
able symptom. The reader must not suppose from this 
that abundant opaque mucous discharges are essential to 
recovery, for they are not, and the patient convalesces 
better if the discharge is never in excess, and but little 
10 



114 STUDY OP DIAGNOSIS. 

changed in character. The typical remedy is Ipecac. 
Change of color evidences local structural disease, and 
disease of the blood, whatever the color may be. 
Shades of yellow and green show suppuration — the dis- 
charge is more or less purulent. Shades of brown, if 
not from blood in this discharge, show a low grade of 
inflammation and impairment of the blood. In some 
of these cases the discharges look like " prune juice," 
or still worse, like the washings of spoiled beef. 

Globular sputa is characteristic of pneumonia, as the 
glairy, tenacious mucus is of bronchitis. So marked is 
this character of the expectoration in inflammation of 
the parenchyma of the lungs, that it is evidenced, not 
only in the single portions of mucus expectorated, but 
when the patient spits in a vessel, they all run together 
to form a globular mass. 

The cheesy expectoration, lacking consistence, seem- 
ing to be somewhat granular, is usually regarded as 
tuberculous. Whilst there are exceptions, it is prob- 
able that it may usually be regarded as evidencing 
aplastic or caeoplastic deposits, and a condition favoring 
tuberculosis, if it is not broken down tubercle. 

Masses of dessicated mucus are sometimes expec- 
torated, that are well calculated to deceive. They are 
in larger and smaller granules, and fully meet the 
popular idea of tubercular deposit. Yet when we take 
a portion and soften it with water on a glass, it gives 
the gluiry, tenacious mucus, and not the friable, tuber- 
cular matter. These little bodies are evidently from 
accumulations in mucous follicles, principally in the 
larynx, which are forced out in the act of coughing. 

Pus from mucous membranes, will in appearance take 
the entire range of this product. It is usually admixed 



STUDY OF DIAGNOSIS. 115 

with mucus, and thus has greater consistence. It is 
laudable, or bad, thin, thick, bland, ichorous, yellow, 
green, brown, etc. It evidences local destruction, 
though it may be but superficial, the relationship be- 
tween mucus and pus being very intimate. The grada- 
tions of pus have the same significance here as elsewhere. 

Blood may be discharged from the throat and pha- 
rynx, from the stomach, from the larynx, and from the 
lungs. From the throat and pharynx it is of usual 
color, is not frothy, and is ejected by an act of the will. 
Blood from the stomach is of darker color, is sometimes 
admixed with food and the secretions of the stomach, 
or is in part clotted. Blood from the larynx is but little 
frothy, is of usual color, and is in part discharged by 
an act of will. Blood from the lungs is usually bright, 
frothy, and wells up into the mouth without the con- 
sciousness of the patient. 

"We always want to know whether hemorrhage is 
active or passive, as the treatment will depend upon 
this. Very fresh and bright blood would evidence 
active hemorrhage, whilst deeper colored blood would 
evidence passive hemorrhage. Yet we will find better 
evidence in the color and expression of the face and in 
the pulse. Active hemorrhage calls for Veratrum and 
Ipecac, whilst passive hemorrhage refers us to Erigeron, 
Gallic Acid and Ergot. 

Mucus streaked with bright blood evidences inflam- 
mation, and is seen in sthenic bronchitis. If the blood 
is less bright it evidences a lower degree of inflamma- 
tion, or rather impairment of the life of the part, and 
if it assumes the " prune juice " character, it evidences 
an unpleasant condition. The blood in the sputa of 
pneumonia is rusty, and may be found perfectly admixed 



116 STUDY OF DIAGNOSIS. 

with the mass of mucus, or forming a central nucleus. 
If here it becomes brown, or has the "prune juice" 
character, it evidences a low grade of inflammatory 
action and impairment of the life. 

We occasionally see exudative material. First, as 
fibrinous exudations from the mucous surfaces, in croup 
and in croupous bronchitis; second, as broken down 
tubercular material from the parenchyma of the lungs. 
The last is sometimes very characteristic, but at others 
it is so masked by the bronchial secretions and by the 
breaking down of the structures, that we can hardly 
recognize it. Call it cheesy, friable, and the fluid dif- 
fering in character from laudable pus in consistence, 
color, etc., and the reader will get a fair idea of it. 

EXAMINATION OF THE URINE. 

The physician in common practice has but little 
knowledge of the urine — possibly he may not know 
the physical properties of normal urine. As we have 
stated so often, this is the first thing that needs be 
learned. If we can recognize normal urine when we 
see it, it will be possible to tell its common variations 
by sight. Yet here we find a serious obstacle in the 
way — the very great variations of normal urine both in 
color and in quantity. Yet there is a normal color, and 
these differences are more in its concentration than in 
any real change. The quantity may vary very greatly 
without any marked change in the excretion — water 
forming its bulk.* 

♦Composition or Renal Excretion. — The renal excretion has 
naturally an acid reaction, and consists chiefly of urea, with some 
wric acid, sundry other animal products of less importance, in- 



STUDY OF DIAGNOSIS. 117 

The majority of physicians attach but little value- to 
the ordinary examination of urine by the sight, which 
is popular!}- known as " Uroscopy." Yet whilst we are 
convinced that there is a broad basis of charlatanry, 
there is evidentl}' something real that serves as a basis 
for selecting remedies. Evidently it is Avorth study, 
and I thiuk I can point out a method by which the 
reader can learn all there is to be known. 

It is claimed that all disease is represented in change 
of the urinary secretions, and that these changes can 
be recognized. Let us admit it, and then to study 
diagnosis by the urine we will take cases of disease 

eluding certain coloring-matters, and saline and gaseous sub- 
stances, all held in solution by a large quantity of water. 

The quantity and composition of the urine vary greatly ac- 
cording to the time of day ; the temperature and moisture of the 
air; the fasting or replete condition of the alimentary canal; 
and the nature of the food. 

Urea and uric acid are both composed of the elements carbon, 
hydrogen, oxygen, and nitrogen ; but the urea is by far the more 
soluble in water, and greatly exceeds the uric acid in quantity. 

An average healthy man excretes by the kidneys about fifty 
ounces, or twenty-four thousand grains of water a day. In this 
are dissolved five hundred grains of urea, but not more than ten 
to twelve grains of uric acid. 

The amount of other animal matters* and of saline substances, 
varies from one-third as much to nearly the same amount as the 
urea. The saline matters consist chiefly of common salt, phos- 
phates and sulphates of potash, soda, lime and magnesia. The 
gases are the same as those in the blood — namely, carbonic acid, 
oxygen, and nitrogen. But the quantity is, proportionally, less 
than one-third as great; and the carbonic acid is in very large, 
while the oxygen is in very small, amount. 

The average specific gravity does not differ very widely from 
that of blood-serum, being 1.020. — Huxley. 



■ 



118 STUDY OF DIAGNOSIS. 

where the diagnosis is well made, and compare the urine 
with the normal standard of health. Certainly we will 
now be able to see these differences if they exist. Here 
is the patient suffering with pneumonia, bronchitis, or 
tuberculosis. Is there a urine that represents pneu- 
monia^ bronchitis, or tuberculosis? Here are patients 
suffering from well recognized nervous lesions, neural- 
gia, paralysis, epilepsy, etc. Is there a urine that rep- 
resents neuralgia, paralysis, epilepsy, etc. ? Here are 
certain well defined lesions of digestion, blood-making, 
nutrition, and retrograde metamorphosis. Are there 
urines that represent these lesions of digestion, blood- 
making, nutrition, and retrograde metamorphosis? 

But supposing we do not find that these diseases are 
represented in the urines, and we can not diagnose the 
situation of local disease from it, possibly we can diag- 
nose a general condition of disease. At least we will 
very certainly learn what is to be learned, and we will 
learn something that is valuable. 

The ordinary examination is conducted with refer- 
ence to — a, quantity; b, specific gravity; c, color; </, 
deposits ; and e, change in its constituents. In every 
day practice the examination is of necessity superficial, 
and it is only when symptoms point to lesions of the 
urinary apparatus, or the disease is so obscure that we 
resort to every known means, that a critical examina- 
tion of urine is made. 

To determine anything definitely with regard to this 
secretion, the urine must be passed in a separate vessel, 
(which should be clean), and the urine of twenty-four 
hours saved for inspection. All tests of color should 
be made in clear white glass containers by means of 
transmitted light, and all deposits should be examined 
in a similar manner. 



STUDY OF DIAGNOSIS. 119 

Quantity. — The normal quantity of urine in the 
healthy man is about fifty ounces in the twenty- four 
hours, and this is of a specific gravity of 1.020, contain- 
ing 1080 grains of solid matter. The urine may mea- 
sure but thirty ounces, yet the specific gravity being 
high, 1.030, the secretion will bo sufficient for blood 
depuration. Again, the urine may be passed in normal 
quantity, or as much as sixty or seventy ounces daily, 
and yet being of low specific gravity, 1 .010, the patient 
will suffer from uraemia There is thus such indefinite- 
ness, that even though we know the quantity of urine 
in twenty-four hours, we can not tell whether depura- 
tion is sufficient or not. 

It may be remarked further that we do not expect 
as large secretion from the kidneys in disease, when the 
body is inactive, as in health when it is active. Scanty 
urine is characteristic of all forms of disease, and even 
an accurate measurement of quantity and specific 
gravity will not tell ns so well whether it is sufficient, 
as other symptoms that might seem to the casual ob- 
server to be more indefinite. 

Specific G-ravity. — The - specific gravity is deter- 
mined by a urinometer. and having the quantity passed 
in twent3 r -four hours, we will, with this instrument, be 
able to determine the amount of solids in this period. 
But it does not determine what solids. If the urine be 
of low specific gravity, and in small quantity, the blood 
may be so freed from urea, that the function may be 
regarded as normal, for there may be but little of the 
"500 grains of other animal matter and saline sub- 
stances " passing out, and the urea for excretion may 
not be more than two or three hundred grains. Con- 



™™ 



120 STUDY OF DIAGNOSIS. 

versely, if the urine be of high specific gravity, and 
passed in considerable quantities, the patient may still 
suffer from uraemic poisoning, for the adventitious solids, 
sugar, albumen, saline matters, etc., take the place of 
urea. 

It is well to get an idea of the uncertainty of this 
examination, otherwise we might be led into error. We 
reach no conclusions from these examinations that are 
not proven by other symptoms ; and usually we make 
these examinations to confirm conclusions reached by 
more definite expressions of disease. If the patient is 
suffering from the nervous excitation or coma of re- 
tained urinary excretion, the examination determining 
scanty urine becomes of value. If the patient shows 
evidence of waste, and we find too free excretion, we 
conclude that this drain upon the blood should be 
stopped. 

In any wrong of innervation, we think of the urinary 
excretion as a possible source of disease, and if we do 
not find the cause elsewhere, we give the urine a critical 
examination. In any disease of debility, especially 
when chronic, if we can not find the cause elsewhere, 
we turn at once to the kidneys as a possible seat of the 
trouble, and make the necessary examination. 

Color.* — The color of the urine has been regarded 
as the best diagnostic evidence in the common exami- 

*TJroh9ematin, the substance which gives to healthy urine its 
peculiar tint, is of more importance to the Clinical Physician 
than the majority of urinary ingredients- for the quantity passed 
in the twenty-four hours is not only an index to the tear and 
wear of the tissues, but the best measure we at present possess 
of the rapidity with which man burns life's lamp. The amount 



STUDY OF DIAGNOSIS. 121 

nation of this fluid. Of necessity, if *any definite in- 
formation is to be had, the urine must be passed apart 
from the faeces, and as before named, it should be exam- 
ined in white glass by transmitted light. 

The physician in ordinary, recognizes the normal 
color varying from a pale straw to a yellowish brown 
tint, and he classes the urine of disease as dark and 
light or pale. Scantj T and high colored urine is asso- 
ciated with acute febrile and inflammatory diseases, 
and pale urine with diseases of relaxation. Possibly 
this is quite as definite as the ordinary professional 
thought, and we may well ask ourselves if there is any 
reason for this indefiniteness. Most assuredly there is ; 
and we find it in the wide range of coloration in health, 
and also in diseases in which color has but little 
meaning.^ 

of all the ingredients of the urine we have hitherto considered, 
are much more under the influence of the diet than that of uro- 
hsematin, the quantity of which may be said to be a tolerably 
exact measure of the destruction of blood corpuscles. — Hurley. 

tThe color of the urine varies greatly in disease. It may be 
perfectly white, yellow, brown, red, black, green, or blue, and 
each of these tints, in the absence of ingesta capable of acci- 
dentally producing them, invariably indicates the existence of 
grave disease. 

Normally colored urine does not, however, exclude the possi- 
bility of disease, for the color of the freshly passed urine is no 
absolute criterion either of the quantity or the kind of coloring 
matter it contains. The abnormal like the normal pigments are 
often combined with some of the other urinary ingredients in the 
form of colorless compounds, and it is not until the compound is 
decomposed, and the pigment set free, that we can take cogni- 
sance either of its quantity or its quality. For example, here are 
three urines: 1st. A pale, almost colorless urine from a healthy 
11 



122 STUDY OF DIAGNOSIS. 

Let us take the opinion of Dr. George Hurley, (and 
I give it in extenso in the foot note.) a most excellent 
observer, that the coloring matter of the urine — uro- 

infant, aged 18 months. It Las a specific gravity of 1 018. 2d. 
An equally pale, almost colorless urine from a girl, aged 19, suf- 
faring from chlorosis- It has also a specific gravity of 1.018. 3d. 
A dark straw-colored, but perfectly transparent urine from a 
health}' man, aged 33. It has likewise a specific gravity of 1.018. 
In fact, these three urines have been purposely selected on 
account of their having the same specific gravity. To each of 
these add a quarter of their bulk of strong nitric acid, and bring 
them to the boiling-point. "Watch the change. The infant's 
pale urine is scarcely altered ; the man's dark urine is only 
slightly deepened in tint; whereas the almost colorless urine of 
the chlorotic girl has assumed an intensely red hue. What is the 
cause of this difference? The infant is in the bloom of health — 
there is no waste of blood-corpuscles in it — all the blood discs it 
possesses are employed in the development of its frame. The 
man has arrived at maturity; he is still in the prime of life, and 
in the enjoyment of perfect health ; his blood-corpuscles are not 
wasted, but merely consumed in the tear and wear of every-day 
life. The young woman, on the other hand, is suffering from 
chlorosis ; she has a pale lip, and a blanched cheek ; her coipus- 
cles are being too rapidly consumed ; her life's blood is oozing 
away by the kidneys, and there it appears as an excess of urohse- 
matin in her urine. 

Take again these two urines so different in appearance. They 
are from young men about the same age (24 years,). The one 
urine is perfectly colorless, like water ; the other is of a deep red 
color — case of hematuria from disease of the kidney. On adding 
Strong hydrochloric acid to the colorless urine it rapidly assumes 
a port wine tint, whereas the same amount of acid added to the 
red urine, instead of heightening, actually destroys the color it 
already possesses. And why? Simply because the pale urine 
contains an excess of combined urohsematin, which is liberated 
by the acid; whereas, the red urine contains merely a number 
of free blood-corpuscles, which become coagulated, and, as th*> 



SlTUDY OF DIAGNOSIS. 123 

hasmatin — represents the wear and tear of the tissues, 
and. especially of the red corpuscles. We might expect 
this to show us definitely the extent of this wear and 



coloring matter in them is insignificant in quantity when com- 
pared with the amount of urohsernatin in the other, no sooner are 
their cell-walls destroyed and the contained hsemato-globulip 
set free and coagulated, than the red color disappears. Now 
which of these two classes of urine denotes the most danger' 
Most assuredly not that containing the free blood-cells. A veri 
small quantity of blood will sometimes color a great deal ol 
urine; whereas an immense destruction of blood-corpuscles may 
take place in the body, and their debris be so eliminated as to be 
invisible to the eye until the application of an acid sets it free 
In fact, experience has shown me that the normally colored urine 
of disease is a most treacherous guide to go by. It often lull? 
the inexperienced into the belief that there is nothing materially 
wrong, when a grave lesion is making rapid strides toward a 
fatal termination. Not very long ago I was told by an intelli- 
gent practitioner that a young lady, regarding whose health we 
were consulting, was laboring under hysteria " The secretions," 
as he termed them, being " all right," my opinion had been 
asked more with the view of satisfying the friends who were get- 
ting fidgety than anything else. The case appeared to be what 
he said, until he added, " She is well fed, and yet she loses flesh, 
and I don't know why." This remark at once brought us back 
to the urine, which he assured me was perfectly natural in color, 
and contained neither sugar nor albumen. I analyzed some, and 
the case proved the very counterpart of the lad's just spoken of. 
Although the girl's urine was natural in color, her life's blood 
was imperceptibly oozing away with it. This is no solitary ex- 
ample: I might cite many cases of so-called hysteria, which were 
in reality cases of serious, though obscure disease ; but that is 
surely unnecessary. Who amongst us has not seen patients die, 
and their disease put down as, only hysteria ? The time is, nev- 
ertheless, not far distant when we shall learn that hysteria is 
something more than "mere functional derangement." Hysteria 
may be a convenient term, but, after all, it is only a cloak of 



124 STtJDY OF DIAGNOSIS. 

tear. But it does not; for as the cases given show, the 
color is not in proportion to the amount of urohaematin, 
but in proportion to that uncombined, and to its degree 
of oxidation. 

ample dimensions which hides the rags of ignorance. It is a 
name instead of an explanation, a sham instead of a reality. 
And what is still worse, it tends to keep us in ignorance by sti- 
fling legitimate inquiry; for no sooner do the majority of practi- 
tioners find a name for the disease than they cease to fathom its 
cause. In some cases of cerebral and spinal disease the excess 
of urohaematin in the urine is so great that after it has been set 
free by an acid and taken up with ether, the ether, after stand- 
ing, solidifies into a red currant jelly-like mass, and may actually, 
in some cases, be cut with a knife. 

The best way of showing this is to boil four ounces of urine; 
then add nitric acid to set the coloring matter free. When cool, 
put the urine into a six-ounce bottle along with an ounce of 
ether. Cork the bottle, thoroughly shake it, and afterwards place 
it aside for twenty-four hours. At the end of that time the ether 
will sometimes be found to be like a red tremulous jelly. Such a 
case is, of course, a very bad one; but these are not nearly so 
uncommon as one would imagine. In some of the worst cases of 
urohsematuria the urine is neutral or even alkaline, and the fons 
et origo mali is to be looked for in the brain or spinal cord. In- 
deed, we may often be led to a correct diagnosis of obscure cere- 
bral and spinal disease, by finding urohsematuria associated with 
a saccharine or a phosphatic condition of the urine. 

In a case of chronic cerebral disease, which I saw with Mr. T. 
Carr Jackson, the quantity of urohaematin regularly varied pari 
passu with the severity of the paroxysms, nitric acid turning the 
urine red, purple, or even bluish (blue matter being after a time 
deposited on the bottom and sides of the test-tube), according to 
the severity and duration of the attack. It ought never to be 
forgotten that alkaline remedies, as well as certain vegetable 
foods, may increase the urohaematin. Even the external use of 
carbolic acid sometimes turns it black. 

When urohasmatin exists in a free state, the urine is red in 



STUDY OF DIAGNOSIS. 125 

Notwithstanding this we always associate the high 
colors or the wrong colors with severe disease. As Dr. 
Harley remarks, " it may be perfectly white, yellow, 
brown, red, black, green or blue, and etich of these 



color before any acid is added. These cases differ from hematu- 
ria, in the urine being clear and transparent, and devoid of 
blood-corpuscles, and from intermittent hematuria in the absence 
of congestive casts. If it contains a deposit, the deposit may or 
may not be high-colored ; but in any case the supernatant liquid 
is clear as well as red. Another fact, which is of great clinical 
importance is, that the urohaematin is not always in the same 
state of oxidation ; and, like indigo, its color depends on the 
amount of oxygen it contains. It may be yellow, red, or brown. 
In consequence of this, different acids act upon the urine differ- 
ently. In one case nitric, sulphuric, or hydrochloric acid may 
produce the same results ; in another hydrochloric acid turns the 
urine red, while nitric acid makes it blue, green, or yellow. In 
a third sulphuric acid may develop the color better than the 
others. 

To illustrate these remarks : Take the case of a gentleman 33 
years of age, whose urine to the eye appeared perfectly normal 
in color. On adding strong nitric acid, however, to this urine it 
immediately became of a blood-red hue, whereas hydrochloric 
acid had no effect upon it until some minutes had elapsed, when 
it gradually caused it to assume the same tint as that produced 
by the nitric acid. When sulphuric acid is slowly added so as to 
fall to the bottom of the test-tube, a reddish-brown line appears 
at the point of contact, and this gradually deepens until, in the 
course of six hours or so, it assumes a more intense color than 
that produced by either of the other acids. 

This is an important case in another point of view, namely, as 
proving the value of urinary analysis in cases of obscure disease. 
The only symptoms that this patient labors under are those of an 
irregular kind of dyspepsia, with an occasional pain in the epi- 
gastrium. He is in easy circumstances, takes plenty of nourishing 
food, wants for nothing, yet he gradually gets weaker and 
weaker, and has lost 17 lbs. in the course of the last year. Even 



126 STUDY OF DlAGNOStS. 

tints, in the absence of ingesta capable of accidentally 
producing them, invariably indicates the existence of 
grave disease " But though we concede the general 
indication, is there any one who can tell the diagnostic 



the locality in which the patient lives is a remarkably healthy 
one (he was sent to me from Anglesey by Dr. D. Williams, of. 
the Menai Bridge), and if it had not been for the condition of 
the urine, his symptoms would have remained a mystery. This, 
too, was one of those cases in which the amount of urohaBmatin 
was so great that it caused the ethereal solution to solidify into a 

jelly. 

An excessive excretion of urohaematin is not limited to cases 
such as we have been describing. It occurs to some extent in 
several diseases, especially those in which there is an excessive 
tissue metamorphosis, and consequent too rapid blood consump- 
tion. Hence we occasionally meet with it in low fevers, in diph- 
theria, in pneumonia, and some other inflammatory affections, 
in lesions of the nervous system, during an attack of gout, after 
the fit of ague, and during convalescence from nearly all grave 
diseases. It is, however, in chlorosis (either in the male or 
female), and the many unnamable obscure affections of that 
class, where it becomes a dangerous symptom. In fact, it always 
indicates the existence of a past or present mischief meriting the 
closest attention of the physician, and where we can not remove 
the cause we must at least attempt to check the effects of the 
symptom, namely, to restore to the blood as much as possible of 
the material which is being drained from it. Every one knows 
the effects of iron upon the system, but iron alone is not always 
sufficient for our purpose. Something more is wanted, and that 
is best supplied by the preparations called the syrups of phos 
phate of iron. Many syrups have been sold under this title. 
There are the American syrups ; the compound syrup of the 
phosphate of iron, or "chemical food,'" as it is sometimes named; 
the syrup of the superphosphate of iron and lime (excellent for 
children) ; and a few others. One and all of them are good in 
particular cases, but they must always be associated with a 



STUDY OF DIAGNOSIS. 12? 

value of each or either of these colors, and make it point 
us to the remedy? This, as the reader will see, is the 
practical question, and I confess that I can not do it. 
In exhaustive disease, in which we may suspect the 

judicious selection of regimen in order that the full benefit may 
be derived from them. 

The preparations of zinc, in grain or grain and a half doses, 
are also occasionally useful astringent tonics when the drain is 
very great. 

In some cases of disease the excretion of urohaematin by the 
kidneys appears to be diminished, but this is only when the sys- 
tem has been so drained that there is little more to come away. 
In the last stage of chlorosis a great diminution in the amount 
of the urohsematin in the urine takes place; so also in chronic 
cases of hematuria, notwithstanding that the urine perhaps 
looks red. Likewise in cases of chylous urine, in the albuminu- 
ria of pregnancy, and in chronic Bright's disease. In all these 
cases the blood has already been well drained of its constituents 
before a marked diminution in the amount of the eliminated 
urohsematin takes place. 

Blue and Green Urine. — A great sensation was created some years 
ago among Clinical Physicians and Pathologists when the first 
cases of blue and green urine were reported ; all doubted, and 
many disbelieved in their existence. The least uncharitable 
thought that the patient had hoaxed the doctor. Knowledge has, 
however, advanced since then. Not one, but many observers 
have met with the same conditions; and now the doubters and 
disbelievers in the existence of either blue or green urine are 
only to be found among the ignorant. 

To Dr. Hassall we owe the first good report on the existence of 
blue urine. It was entitled — "On the Frequent Occurrence of 
Indigo in Human Urine, and on its Chemical, Physiological and 
Pathological Relations." 

I must here guard you against falling into the common error 
of supposing that the urine is blue or green at the moment of 
being voided, for, as far as I am aware, such a condition has 



128 STUDY OF DIAGNOSIS. 

removal of the blood corpuscles by way of the kidneys, 
the addition of Nitric, Muriatic or Sulphuric Acid to 
the urine may give us the evidence of this masked 
hemorrhage through these organs. The directions 
given in the foot note may be followed. 

never yet been observed. In the cases, hitherto reported it has 
only been after exposure to the air, or after the application of 
chemical agents, that the urine has been observed to become of 
the colors alluded to. In Hassall's best-marked case, for exam- 
ple, the urine was of a light brown color when voided, somewhat 
alkaline, and had a specific gravitj T of 1.017. In the course of 
three or four days it became thick and turbid, deep brown, 
greenish, bluish-green, yellowish-green, and finally nearly black: 
the scum on the surface remaining of a permanent, deep indigo- 
blue color. All these changes followed upon simple exposure to 
the air; but, as just said, chemical agents may produce one or 
more of these changes. Thus, for example, in Munk's case of 
green urine, when passed the urine was of a dark red color, but 
on the addition of ammonia it became green. Like everything 
else when properly understood, these changes have nothing mys- 
terious about them. The body has not crented anything new in 
making blue or green urine. Indeed, as in disease no new func- 
tions are ever created, but only a change occurs in the ihythm 
and force of those already existing, so in disease no new sub- 
stances are ever created, but only a change takes place in the 
quantity or in the quality of those normally existing. It is now 
twelve years since I adopted these views, and the longer and 
deeper I peer into the wondrous workings of the human frame, 
the more am I satisfied with them, and the easier do I find the 
comprehension of disease. Physiology and Pathology are but 
one study; and although a man may be a Physiologist without 
being a Physician, no man can be a Physician without being a 
Physiologist. The same laws that regulate health regulate dis 
ease. The very effects we are now studying are a striking illus- 
tration of the justice of these observations. 



STUDY OF DIAGNOSIS. 129 

Deposits* — A deposit from the urine is " always a 
sign of something wrong," but, unfortunately, it does 
not always determine for us the character of the wrong, 
or the remedy. To obtain a deposit, the urine is passed 
in a separate vessel, which being covered, is allowed to 

*A deposit in the urine is always a sign of something being 
wrong, and although, as we have seen, it may occur from very 
trivial causes, whenever it takes place without appreciable cause, 
in the otherwise apparently healthy, it is a sign not to be disre- 
garded, as, under such circumstances, it is not unfrequently either 
the forerunner or associate of gravel or stone. Uric acid in 
some form or other is the commonest ingredient of all calculi, 
and there is no period of life exempt from them. 

Urates are a very common deposit in the course of acute dis- 
ease, and they even seldom fail to recur at some period or other 
in the course of chronic affections. It is, however, only in dis- 
eases of an acute febrile or inflammatory type that their sudden 
appearance can be regarded as indicative oft, crisis. Their sud- 
den appearance is due to an important change having occurred 
in the condition of the patient, and in general, though not 
always, it is a change for the better. Such, for example, is ob- 
served to occur in cases of gout and rheumatism where the climax 
has been reached. So also in pneumonia and pleurisy when re- 
solution and absorption commence. 

Should a patient, not laboring under any febrile or inflamma- 
tory affection, be every now and then troubled with a pink de- 
posit in the urine without any assignable cause, it will be found, 
in almost nine cases out of ten, that he is suffering from some 
chronic affection of the heart, liver, or spleen, with which is asso- 
ciated a tendency to gravel. In all such cases, therefore, steps 
should immediately be taken to counteract this disposition by the 
administration of alkaline tonics. Should there, however, be any 
eounter-indication to the direct alkaline treatment, those acid 
salts are to be employed which, during their passage through the 
body, are converted into alkaline carbonates — such, for example, 
as citrates, tartrates, lactates, and acetates. Every now and then 



130 STUDY OF DIAGNOSIS. 

stand fi^m one to twelve hours. It is not well to ex- 
amine deposits from old urine, urine admixed with 
faeces, or urine in a chamber utensil that is continuously 
foul for want of proper washing. Urine undergoes de- 
composition, and this will give rise to some deposits ; 
faecal matter will obscure the subject, and a utensil that 
is allowed to contain decomposing matter will set up 
processes of change in urine recentl}^ passed. 

With regard to the value of deposits I can not do 
better than quote from Grolding Bird, as his methods 
are the clearest I have seen : 

"On the Clinical Examination of the Urine. — 
The following observations may be of service to the 
practitioner, as a guide to his proceedings in the super- 
ficial examination of the urine, the most important part 
of which can be readil} 7 performed in a few moments 
in the sick room. Premising that the urine presented 
for inspection is either an average specimen of that 
passed in the preceding twentj^-four hours, or at least 
that resulting from the first act of emission after a 
night's rest, unless the urine secreted at other times of 
the day be specially required. 

" Urine without any visible deposit, or decanted from the 
sediment. — A piece of litmus paper should be immersed 
in the urine, which, if acid, will change the blue color 
of the paper to red. Should no change occur, a piece 
of reddened litmus paper must be dipped in, and if the 
secretion be alkaline, its blue color will be restored ; 
but if its tint remains unaltered, the urine is neutral. 

an exceptional case may arise, where a mineral acid tonic is de- 
manded; under such, circumstances the above rule may be de- 
parted from, and the case treated according to its special require- 
ments. — Harley. 



STUDY OF DIAGNOSIS. 131 

"Some of the urine should then be heated in a pol- 
ished metallic spoon over a candle, or, what is prefer- 
able, in a test-tube over a spirit lamp, and if a white 
deposit occurs, albumen or an excess of the earthy 
phosphates is present ; the former, if a drop of nitric 
acid does not redissolve the deposit, the latter, if it 
does. 

kS If the urine be very highly colored, and not ren- 
dered opaque by boiling, the coloring matters of bile, 
or purpurine, are present. To determine which, pour 
a thin layer of urine on the back of a white plate, and 
allow a few drops of nitric acid to fall in the centre : an 
immediate and rapidly ending play of colors, from 
bluish-green to red, will be observed if bile, but no such 
change will be observed if purpurine alone exists. 
Should the highly colored urine alter in color or trans- 
parency by heat, the presence of blood must be sus- 
pected. 

" If the addition of nitric acid to deep red urine, un- 
affected b}^ heat, produces a brown deposit, an excess 
of uric acid exists. If a specimen of urine be pale, 
immerse the gravimeter, and if the specific gravity be 
below 1.012, there is considerable excess of water, but 
if above 1.025, the presence of sugar, or a superabun- 
dance of urea is indicated. To determine the existence 
of either of these conditions, place* a few drops of the 
urine in a watch-glass, add an equal quantity of nitric 
acid, and allow the glass to float on some cold water ; 
crystals of nitrate of urea will appear in two or three 
minutes, if the latter exists in excess. Should this 
change not occur, the urine must be examined specially 
for sugar, which, it must be remembered, ma} 7 exist in 
small quantities, without raising the specific gravity of 



132 STUDY OF DIAGNOSIS. 

the fluid. For this purpose boil a small portion with 
an equal bulk of liquor potassae in a test-tube, and the 
development of a brown color will at once afford evi- 
dence of* the almost certain existence of sugar. An 
excess of coloring matter, rich in carbon, should always 
be sought after, on account of its pathological import- 
ance. This is readily done by boiling some urine in a 
tube, and, whilst hot, adding a few drops of hydro- 
chloric acid. If an average proportion of the pigment 
exist, a faint red or lilac color will be produced ; but if 
an excess is present, it will be indicated by the dark 
red, or even purple tint assumed by the mixture. 

" Should the urine be alkaline, add a drop of nitric 
acid ; if a white deposit occurs, albumen is present ; if 
brisk effervescence follows the addition of the acid, the 
urea has been converted into carbonate of ammonia. 

" Examination of the Sediment Deposited. — If the de- 
posit is flocculent, easily diffused on agitation, find 
scanty, not disappearing on the addition of nitric acid, 
it is chiefly made up of healthy mucus, epithelial de- 
bris, or oecasionally, in women, of secretions from the 
vagina, leucorrhoeal discharge, etc. 

" If the deposit be ropy and apparently viscid, add a 
drop of nitric acid ; if it wholly or partly dissolves, it 
is composed of phosphates, if but slightly affected, of 
mucus. If the deposit falls like a creamy layer to the 
bottom of the vessel, the supernatant urine being co- 
agulable by heat, it consists of pus. 

" Urine sometimes appears opaque, from the presence 
of a light flocculent matter diffused through it, neither 
presenting the tenacity of mucus, nor the dense opacity 
of pus. Although scarcely sufficient in quantity to in- 
terfere with the perfect fluidity of the urine, if a little 



STUDY OF DIAGNOSIS. 133 

be placed in a test-tube and agitated with an equal bulk 
of liquor potassae, the mixture will often become a stiff, 
transparent jelly. This peculiar appearance is demon- 
strative of the presence of the exudation, or large or- 
ganic globules formed under the influence of irritation, 
providing the urine does not coagulate by heat, for 
should it do so, the existence of minute quantities of 
pus maybe suspected. 

"If the deposit be white, it may consist of urate of 
ammonia, phosphates, or cystine ; the first disappears on 
heating the urine, the second on the addition of a drop 
of diluted nitric acid, whilst the third dissolves in am- 
monia, and the urine generally evolves an aromatic 
odor like the sweetbrier, less frequently being fetid. 

" If the deposit be colored, it may consist of red par- 
ticles of blood, uric acid, or urate of ammonia, stained 
with purpurine. If the first, the urine becomes opaque 
by heat; if the second, the deposit is in visible crystals; 
if the third, the deposit is amorphous, and dissolves on 
heating the fluid. 

" Oxalate, and more rarely oxalurate (?) of lime are 
often present diffused through urine, without forming a 
visible deposit : if this be suspected, a drop of the urine 
examined microscopically will detect the characteristic 
crystals. 

" If the urine be opaque like milk, allowing by re- 
pose a cream-like layer to form on the surface, an emul- 
sion of fat with albumen is probably present. Agitate 
some of the urine with half its bulk of ether in a test- 
tube, and after resting a few minutes, a yellow ethereal 
solution of fat will float on the surface of the urine — a 
tremulous coagulum of albumen generally forming be- 
neath it. 



134 STUDY OF DIAGNOSIS. 

" Much of the little time required for the investiga- 
tion thus sketched out, may be saved by remembering 
the following facts : 

" If the deposit be white, and the urine acid, it in the 
great majority of cases consists of urate of ammonia ; 
but should it not disappear by heat, it is phosphatic. 

" If a deposit be of any color inclining to yellow, 
drab, pink, or red, it is almost sure to be urate of am- 
monia, unless visibly crystalline, in which case it con- 
sists of uric acid. 

"The following tables briefly point out the readiest 
mode for the examination of crystalline deposits, both 
by chemical tests and by microscopic examination. 
The latter mode is of course preferable to all others, 
both for the accuracy and extent of the information it 
affords, as well as for economy of time : 



TABLE FOE DISCOVERING THE NATURE OF URINARY DEPOSITS BY CHEMICAL RE- 
AGENTS. 

» (Deposit white, 2 

t " colored, 5 

„( " dissolves by heat, Urate of ammonia. 

\ <l insoluble by heat, 3 

of " soluble in liquor ammonise,... Cystine. 
\ " insoluble in, " ... 4 

soluble in acetic acid, Earthy phosphates. 

insoluble in " Oxalate and oxalurate of lime. 



,{ 



visibly crystalline Uric acid. 

amorphous, 6 

pale, readily soluble by heat, Urates, 
deeply colored, slowly soluble 

by heat Urates, stained by purp^rine. 



TABLE FOR THE MICROSCOPIC EXAMINATION OF URINARY DEPOSITS. 



-. '{Deposit amorphous, 2 

I " visibly crystalline, 3 



" vanishes on the addition of 

liquor potasses, Urate of ammonia. 

" permanent after the addition 

of liquor potassse Phosphate of lime. 



2. 

• j Crystals in well defined octahedra, Oxalate of iime 

* 1 " not octahedral, 4 



STUDY OF DIAGNOSIS. 135 



{Crystals in six-sided tables, soluble in 
ammonia, Cystine. 
" not tabular, nor soluble in 

ammonia, 5 



- ( " soluble in aeetic acid, 6 



insoluble in acetic acid, 8 



- f " in prisms or simple pennse,... Neutral triple phosphate. 
°* \ " radiated or foliaceous 7 

soluble in acetic acid with ef- 

?.^ fervescenee Carbonate of lime. 

soluble in acetic acid without 

effervescence Bibasic-triple phosphate. 

in dumb-bells or radiated, Oxalurate (?) of lime. 

spherical or colored, 

in lozenges or compound 

9. -4 " crystals, Uric acid. 

in spherical crystals Urate of soda or ammonia. 



EXAMINATION OF THE FAECES. 



The Bowels. — Excretion by the bowels does not 
hold that importance now that it did in olden times. 
We learn by experiment that of the four to six ounces 
of faeces, giving one to one and a half ounces of solid 
residue, but about 100 grains are of excrementitious 
matter.* 

The liver, which was formerly thought to play so im- 
portant a part in removing waste of tissue, and excre- 
mentitious matter, yields but a few grains of this (four 
to eleven grains). It has also been conclusively deter- 
mined that there are no agents that act upon the liver, 
increasing its secretion {cholagogues) ; that mercury in 
any of its forms does not influence it in the least, ex- 
cept when it produces its constitutional effect, and when 
given to catharsis, it lessens the secretion. Ail cathar- 
tics in cathartic doses diminish the secretion. Even 
our Podophyllin, which has been regarded as a Samson 

*See Principles of Medicine, p. 126. 



136 STUDT OP DIAGNOSIS. 

in its influence upon the liver, diminishes the secretion 
in cathartic doses, and in minute doses lessens the "bile 
solids while it slightly increases the quantity excreted. 

If we can learn that the liver performs an important 
function in digestion and in blood-making, furnishing 
its secretion for these purposes, and that it is admirably 
adapted to these purposes, and rarely the subject of 
disease, and that we have no medicines that influence 
it directly, to increase secretion, we will have made an 
important advance in pathology, and will have much 
improved our therapeutics. We may classify it with 
the pancreas, and may expect to influence it only by 
those remedies that control the circulation, act through 
the sympathetic nervous system, and influence the pro- 
cesses of blood-making. 

Our inquiry in regard to the faeces will have refer- 
ence, first, to the increase or diminution of the secre- 
tion ; second, to the condition of the intestinal canal, 
as an apparatus for digestion ; and third, to any abnor- 
mal constituent, or marked change in the character of 
the excretion. 

Increase of the faeces, in proportion to its extent and 
duration, causes debility; for histogenetic material, 
either as food or tissue, is proportionably removed. 

Fluid faeces, whilst very frequently in excess as above, 
deserve attention more particularly as evidencing such 
lesion of the intestinal canal, as interferes with diges- 
tion and blood-making ; and also with that due degree 
of distension of the blood vessels, which is necessary 
to proper circulation. 

Deficiency of faeces may depend upon the quality of 
the food, or upon its quantity; the largest proportion 
of faecal material being furnished by the debris of 



STUDY OF DIAGNOSIS. 137 

food; or it may depend upon au arrest of secretion, in 
which case we will have the same constitutional evi- 
dence that we would have in similar arrest from the 
skin and kidneys ; or it may be dependent upon atony 
of the intestinal canal, which allows the material to ac- 
cumulate, without the natural effort at removal. 

Simple constipation gives rise to derangements of 
digestion, and the retention of effete material in the 
bowels occasions a feeling of malaise and dullness, with 
headache and fever, in so far as they are retained in 
the blood, or re- absorbed. 

The color of the discharges is sometimes of import- 
ance in determining the character of disease. The 
natural color, like the natural fetor, evidencing a con- 
dition of the intestinal canal in which its functions may 
be properly performed. 

The dark-brown or almost black color of the faeces, 
observed in typhoid disease, arises from the excretion 
of the coloring material of the blood ; the red globules 
being broken down rapidly. 

The use of iron in any of its forms, and occasionally 
of sulphur or its salts, will darken the color of the faeces. 
The dark-green color of the faeces that followed the ad- 
ministration of mercury, and was thought to be bile, 
was due to the formation of sidphuret of mercury. 

Greenish discharges are generally dependent upon an 
increase of acid in the intestinal canal, with irritation 
and consequent indigestion. It may, in part, be de- 
pendent upon the coloring matter of bile, which is 
thrown off by the faeces, in consequence of such irrita- 
tion. 

Clay-colored discharges refer to a general want of 
secretion ; not only of the solitary glands of the intes- 
12 



138 STUDY OF DIAGN08IS. 

tine, but of the associate viscera. It is an atonic con- 
dition, with impaired innervation and circulation. 

The natural odor of faeces seems to be dependent upon 
a special secretion in the neighborhood of the caecum. 
It may be regarded as an evidence of normal activity 
throughout the entire intestinal track. 

Diminution of the odor is an indication of want of 
functional activity, as an increase will indicate in- 
creased activity. 

Fetor refers to decomposition of the intestinal secre- 
tions. It varies greatly from local causes, and can not 
be relied upon as indicating any special condition of 
the general system. 

The cadaverous fetor may, however, be taken as evi- 
dencing a septic condition, not only of the intestinal 
secretions, but also of the fluids and solids. 

It is difficult to determine change in the elements of 
faeces, and it will hardly form a part of ordinary ex- 
aminations. The principal of these I append, Lehman's 
Chemical Physiolog} T being the authority, 

" The excrements in consumption are sometimes 
found to contain more fat than usual. Sugar is occa- 
sionally found in the faeces of diabetic patients. The 
stools are found to be black, chocolate-colored, or tar- 
like, when blood is contained in them, and this arises 
from the upper intestinal canal ; so also the semi-liquid, 
green excrements which are observed occasionally in 
typhus and other diseases, depend upon blood, which is 
easily recognized by the microscope. Soluble albumen 
is found in the stools in dysentery, typhus, and occa- 
sionally in Bright's disease, and in cholera. The great- 
est quantity of epithelial cells are found in the dejec- 
tions of cholera. Cytoid corpuscles are very numerous 



STUDY OF DIAGNOSIS. 139 

in the excrements in catarrhal diarrhoeas, in dysentery, 
and Occasionally in typhus and cholera. Hyaline mucus 
is observed in the excrements in catarrh of the large 
intestine; it arises from the follicles of the colon, and 
contains round or oval pale or granular cells and cell 
nuclei. Fibrinous exudations occur in the fseces in folli- 
cular ulceration and in dj^senteiy." 



DIAGNOSIS BY THE TOUCH. 

In our study of the senses, we found that the tactile 
sense could be wonderfully developed. Marked exam- 
ples of this may be found in the mechanic arts, not 
only of extreme delicacy, but of complex and difficult 
work accomplished through this sense alone. The 
education of this sense in the blind is another marked 
example, and it is well that a physician should make 
himself acquainted with the education of the blind, to 
see the range of this sense which in the majority has 
such imperfect development. 

What information can we gain by the sense of touch ? 
]S"ot much, one would say at first thought; } T et we find 
it an important means of diagnosis if we stud} T it care- 
fully, and train the sense of touch The obstetrician 
relies wholly upon it, not only determining the presen- 
tation and position of the child, but the condition of 
every part engaged in the process. His touch tells him 
the condition of the depending portion of the uterus as 
an outlet,-and also the condition of the organ as re- 
gards the power of expulsion. It determines the con- 
dition of the vagina as a parturient canal, and becomes 
bo sensitive that it recognizes intuitively changes of 



140 STUDY OF DIAGNOSIS. 

condition that will render the labor painful, protracted, 
or difficult. In diseases of women, many physicians 
rely upon the sense of touch far more than sight, and 
very rarely use the speculum. The finger tells the 
condition of the uterus, not only as regards position, 
but pathological changes as well. It determines dis- 
eases of vagina, bladder, rectum, indeed of all these 
parts, and does it so well that it becomes our most re- 
liable guide to treatment. 

I will guarantee that there is not one medical reader 
but what could to-day, blindfolded, determine better 
by simply placing his hand on the patient what kind 
of a bath should be employed, or whether any at all, 
than he can with his eyes open and without the touch. 
Try the touch in cases of intestinal disease, shutting 
your eyes to shut out ordinary impressions, and you 
will be astonished at the result. Pass the hand over 
the abdomen and at once you know whether a diarrhoea 
is irritative or atonic, and a correct treatment is sug 
gested. You may determine the character of a dys- 
pepsia in the same way, and the general outline of 
treatment. You can locate the disease and determine 
its kind. Even in uterine disease the abdominal touch 
becomes important. Try a ease of pneumonia — let the 
hand rest on the chest, slowly passing it over, and you 
will be surprised to know how much may be learned — • 
a Winter's practice, and it becomes a means of ph} T sical 
diagnosis. 

A most excellent way of making this study is to take 
a note-book and enter every question that may suggest 
itself with reference to the various sensations given to 
touch. Then question our experience — when and where 
have I met each of these ? what has been the nature, 



STUDY OF DIAGNOSIS. 141 

progress, duration, and termination of the disease. 
Now with what we know we will carry on a series of 
experiments in every case of disease, making use of 
what we have for the benefit of the patient, and learn- 
ing what we can for the advantage of others in the 
future. 

Let me put a few questions which will serve as an 
example. If I put m} T finger on the tongue, and find 
it dry, contracted, or rough, would you give Podo- 
phyllin ? an emetic? Quinia? Opium? or a stimulant ? 
If I put my hand on the abdomen and find the walls 
tense and contracted, the patient having diarrhoea, 
what will be the remedy ? If relaxed and tumid what ? 
If in uterine disease the abdominal wall is tense and 
contracted, what is the nature of the disease ? If all 
the tissues are soft, full, doughy, what ? If the hand 
placed upon the forehead gets the sense of relaxation 
and moisture, what would be the character of a head- 
ache ? If the forehead was tense and dry, what? I 
offer these as examples of questions that one may ask 
himself, and as the reader will see they can fre greatly 
varied, and asked of every part of the body, as well as 
of the body as a whole. Ask then with reference to the 
conditions of disease, but especially with reference to 
remedies, as the diagnosis that suggests treatment is 
that which we want especially. 

In a case of labor, if the examination shows constric- 
tion with want of secretion — pinched expresses the con- 
dition of the parts, both of the lower segment of the 
uterus, vagina, and perineal tissues — we know we will 
have a protracted and difficult labor. If the hand is 
placed upon the abdomen over the uterine globe and 
we get the same sensation of unnatural contraction — 



142 STUDY OF DIAGNOSIS. 

pinched — there is possibly rigidity of os, or perineum ; 
what is the remedy ? You answer Lobelia, because it is 
the common remedy for rigid os and perineum. But jon 
give it without any advantage, and it sometimes causes 
a very unpleasant irritation of the stomach and nervous 
system, and makes things worse rather than better. 
Let us ask your hand in place of your head. If this 
was a headache, and j t ou had a similar sensation when 
your hand was placed on the patient's forehead, what 
would you give ? You answer promptly, G-elseminum . 
good, then give G-elseminum and not Lobelia. If upon 
examining muscular tissues you had the same unplea- 
sant sensation of contraction and irritability with pains 
what would you give ? Aconite or Yeratrum with 
Macrotys — good, give Aconite and Macrotys in this 
case. If in chronic disease of the pelvic viscera we ob- 
tained the same sensation as the hand rested upon the 
lower abdomen, Avhat would we give? G-elseminum, 
Aconite, Macrotys. 

If in this examination during tedious labor, we found 
the tissues thick and doughy, with rigid os and rigid 
everything else, what would we give ? With this con- 
dition shown by an internal examination, the hand 
placed upon the abdomen would receive the same sensa- 
tion of unnatural fullness and want of action. Here 
we would give Lobelia. The touch tells the stoiy 
clearly and explicitly, and names the remedy, which we 
find upon trial acts ' : specifically." Supposing now it 
should be pneumonia or bronchitis, and the hand placed 
upon the chest gets the same sensation of unnatural 
fullness, would the remedy be Lobelia? Or if the 
finger placed upon the tongue obtains the sensation of 
doughy fullness, or the eye obtains it, would the remetiy 



STUDY OF DIAGNOSIS. 143 

b.e Lobelia? Most assuredly,' unless something else 
acting in the same way is more prominently indicated 
by other symptoms. 

In speaking of the touch as a means of diagnosis, 
we must not omit to notice the lesions of nutrition and 
excretion — supply and waste. How do you determine 
impaired nutrition? Surely not by the fullness or lean- 
ness of the face? if you do you are frequently mistaken 
You want to know if the loss of size and weight i? 
from want of fat or muscle, and your hand at one? 
seeks the covering of the false ribs for the one, and 
grasps a group of muscles — say of the arm, for the 
other. It would be absurd to feed a patient with beef 
tea or other histogenetic material if we wanted fat, 
though we might give calorifacient food to save 
tissue. 

We not only get the evidence of impaired nutrition 
by the touch, and the food designated, but it tells us of 
medicines that will prove curative. If the sensation be 
of want of tone — tissues loose and flaccid — we think of 
Bitter Tonics, Quinine, the Hypophosphites, and Iron. 
If the sensation be of structures pinched and stringy, 
we look for lesions of the nerve centres, and think of 
Macrotys, Muriatic and Lactic Acids, Phosphoric Acid, 
fatty inunction, etc. 

The sensation of fullness without elasticity, would 
suggest old tissues, and the necessity of active waste, 
and would suggest Acetate of Potash, Iodide of Potas- 
sium, and stimulant cathartics and diaphoretics. If 
digestion remained good, these might be sufficient, for 
the tissues would be renewed as fast as broken down. 
But if their use gave soft and flaccid tissue, we should 
supplement them by such a restorative as the triple 



144 STUDY OF DIAGNOSI8. 

phosphate of Quinia, Strychnine and Iron — "Com- 
pound Tonic Mixture." 

We would never give Iodide of Potassium in second- 
ary syphilis, where the tissues give the pinched and 
stringy sensation to the touch. Such a case would ask 
for Yeratrum. Cod Oil. Iodide of Ammonium, and some 
would say Arsenic. Let one of those cases of secondary 
syphilis, characterized by full, inelastic, lifeless tissues 
fall into the hands of the routinist who prescribes Pro- 
toiodide of Mercury in all cases, and he loses appetite, 
digestion and blood-making, and grows worse rapidly. 

This is but an imperfect and partial sketch of one of 
our means of diagnosis, and one that has been regarded 
as least useful. Yet it points out the method of rational 
diagnosis, and the one we purpose studying in consid- 
erable detail. As the reader thinks of the subject, and 
recalls and arranges his experience, he will be surprised 
how much he knows practically, and still more sur- 
prised as he puts it in practice intelligently, how it aids 
him in the selection of remedies. 



THE PULSE. 

Among the most important of the functions of life is 
a normal circulation of blood, indeed it seems to serve 
as a basis for the performance of ail other functions. 
Healthy life is dependent upon a regular and uniform 
circulation of blood, and disease must follow any con- 
siderable or continued variation in this function.* 

*If the finger be placed upon nn artery, such as that at the 
wrist, what is termed the pulse will be felt; that is to say, the 
elastic artery dilates somewhat, at legular intervals, which an- 



STUDY OF DIAGNOSIS. 145 

Wbilst the heart is the centre and principal source 
of power of the circulation, every vessel does its part 
in aid of the movement of the blood. We have, there- 
fore, to determine by the pulse the condition of the 
heart, the condition of the arteries, the condition of 
the capillaries, and to some extent the condition of the 
veins. As these movements are stimulated and co-or- 
dinated by the sympathetic nervous system, it should 
also tell us of wrongs of innervation. As the move- 
ment of the blood depends, to a certain extent, upon its 
organization and condition, it may also determine for 
us something of the wrongs of this fluid. 

We will probably study the pulse to better advantage 
if we analyze it, and think of its elements separately. 
Put your finger on the radial artery and carefully ob- 
serve the movement. It first divides itself into : (a) a 



swer to the beatings of the heart. The pulse which is felt by the 
finger, however, does not correspond precisely with the beat of 
the heart, but takes place a little after it, and the interval is 
longer the greater the distance of the artery from the heart. 
The beat of the artery on the inner side of the tinkle, for exam- 
ple, is a little later than the beat of the artery in the temple. 

The reason of this is that the sense of touch by finger is only 
delicate enough to distinguish the dilatation of the artery by the 
wave of blood, which is driven along it by the elastic reaction 
of the aorta, and is not competent to perceive the first shock 
caused by the systole. But, if, instead of the fingers, sufficiently 
delicate levers were made to rest upon any two arteries, it would 
be found that the pulse really begins at the same time in both, 
the shock of the systole making itself felt all over the vascular 
system at once; and that it is only the actual dilatation of the 
arterial walls, which, traveling in the form of a wave from the 
larger to the smaller arteries, takes longer to reach and distend 
the more distant branch. — Huxley. 
13 



146 STUDY OF DIAGNOSIS. 

dilatation of the artery, and (6) a succeeding contrac- 
tion The wave of blood forced forward by contraction 
of the ventricles, gives us the arterial dilatation, whilst 
the contraction of the artery may represent the subse- 
quent filling of the ventricles from the auricles. 

To this extent the pulse evidences the time of con- 
traction, or the rapidity of heart-beat. Even to this 
extent the information is important, for a healthy life 
can only be maintained when the movement of the 
blood is well timed. If the heart beats too rapidly, we 
must have a wrong in the life, as if it beats too slowly 
we will have a wrong in the life. 

With regard to frequency of pulse we are in the habit 
of saying — as is the frequency so is the impairment of 
all the vegetative functions — of the appetite, digestion, 
blood-making, nutrition, excretion from skin, kidneys 
and bowels — wrongs of the blood, the activity of zymotic 
poisons, etc. There may be exceptions to this general 
rule, but it is so constant that we find it important to 
act upon it in every case of disease. Given, frequency 
of pulse, the questions at once suggested are — what is 
its cause? what is the remedy ? 

Whilst frequency of pulse suggests to us the use of 
that class of remedies called sedative (special or arte- 
rial sedatives), they will not always answer our pur- 
pose. If the wrong be purely one of the circulatory 
apparatus, functional in its character, and depending 
upon a wrong of sympathetic innervation, these reme- 
dies will probably be sufficient. But if the frequency 
of pulse represents and is dependent upon some other 
lesion, as of the blood, or local disease, then other and 
different remedies may prove the sedatives. 

Frequency of pulse is associated with frequent respi- 



STUDY OF DIAGNOSIS. 147 

ration. The proportion is usually five beats of the 
pulse to one respiration. Thus an adult man in the 
sitting position will make thirteen to fifteen respirations 
each minute, and the proportionate pulse will be sixty- 
five to seventy-five beats per minute. With a pulse of 
one hundred and ten beats per minute, we will have 
twenty-two respirations per minute. The relation of 
frequent respiration to various wrongs of function wil' 
be known to the reader, and evidently a slower respi 
ration is something to be desired in all cases of disease, 
and something that must be obtained in some cases if 
the patient recovers health. 

Without reference to the undue general excitation 
that comes from frequent respiration, and the exhaus- 
tion that must folloAv this severe muscular work, I 
would call attention to the marked wrong it must work 
in diseases of the respiratory apparatus. Rest is an 
essential to recovery in all diseases of excitation, and 
in most diseases of structure. With a rapid pulse, we 
can not have rest of the respiratoiy apparatus, for the 
movement of the chest is related to the movement of 
the blood. Make the pulse go slow, and the movement 
of the chest is likely to be slow in proportion. 

The relation between the frequency of pulse and the 
temperature will be borne in mind. For each increase 
of ten beats per minute of pulse, there is an increase 
of one degree in the temperature. Thus with a normal 
circulation of seventy beats per minute, and a normal 
temperature of 98°, we will find an increase of pulse to 
ninety will give a temperature of 100° ; with an in- 
crease of pulse to one hundred and twenty we wil.l have 
a temperature of 103°, and so on. This rule does not 
hold good in all cases, possibly not in the majority . for 



148 STUDY OF DIAGNOSIS. 

the high range of temperature, from 103° to 108°, does 
not carry the pulse up proportionately. 

When we come to consider the influence of changes 
of temperature we find them similar to those that 
follow change in the time of pulsation. In the ratio 
of increased temperature we find arrest of excretion, of 
nutrition, of digestion, of blood-making, and of inner- 
vation, and that zymotic poisons propagate themselves 
more rapidly. With the temperature maintained above 
103°, death is a matter of time, indeed molecular death 
is going on from the time the temperature strikes this 
point. 

It was mentioned that local processes of disease are 
severe in proportion to the frequency of the pulse. 
This will be noticed especialh r in inflammation — as is 
the frequency of the pulse so is the intensity of the in- 
flammation, the impairment of the life of the part, and 
the danger of a termination in death. The local hyper- 
emia is increased by the rapid pulse, and the final 
arrest of circulation is also promoted b}^ it. If, there- 
fore, we wish to stop the process of inflammation, we 
select those remedies which will lessen the frequency 
of the pulse. 

If in any case we have a structural lesion, whatever 
may be its nature — either an impairment of nutrition, 
or from deposit — we will find, frequently, that its pro- 
gress will be in proportion to the rapidity of the pulse. 
In these cases remedies that influence the circulation, 
giving it normal frequency and freedom, will be very 
important. 

It was also named that zj-mosis or sepsis was rapid 
in proportion to the frequency of the pulse. This may 
be noticed in those diseases known as typhoid, in ery- 



STUDY OF DIAGNOSIS. 149 

Bipelas, the eruptive fevers, diphtheria, as well as in 
typhoid and typhus fever. As is the frequency of the 
pulse, so is the evidence of sepsis, as marked by dirty, 
brown, or black coatings on the tongue, sordes on the 
teeth, pungent heat, offensive discharges, etc. The 
danger to life is frequently in proportion to the fre- 
quencj T of the pulse, and means that will give a better 
circulation as regards time, freedom, and uniformity 
in all parts of the body, lessen those unpleasant 
symptoms. 

But frequency is only one of the wrongs of the cir- 
culation, and but a part of the information we should 
obtain from the pulse, Frequency has reference to the 
rapidity of the blood- waves — the number that passes 
under our finger in one minute. In addition to this we 
have to notice that there are peculiarities in the blood- 
wave, and in the current after this wave has passed. 
The pulse has volume — referring to the size of the 
artery. It has varying impulses in the wave of the 
blood, and also in the interval between the waves. 

Volume, or increased size of the artery may have 
reference to the amount of blood, to its increased circu- 
lation, or to some obstruction to its free movement. 
We will have a large pulse in the plethoric, we may ex- 
pect a small one in the ansemic, and these conditions 
will be determined by other evidences. If the artery 
is large, and the person is not plethoric, we ask the 
question — is it dependent upon a more rapid movement 
of the mass of the blood, especially to the surface, or is 
it dependent upon an obstruction to its movement 
through the capillaries ? Freedom in the pulse-wave in- 
dicates the one, and a want of freedom — oppression — 
indicates the other condition. 



150 STUDY OF DIAGNOSIS. 

The sharp impulse of the wave of blood, as it strikes 
the finger, may be referred to lesions of the nerve cen- 
tres, especially of the sympathetic. The wrong is of 
irritation, and calls for remedies that relieve it. If 
the impulse be sharp, the wave short, and the inter-cur- 
rent vibratile, the irritation is extreme. 

The dull, elastic stroke of the wave refers us to an 
impairment of innervation from the sympathetic and 
spinal cord. The more marked this is, the greater the 
necessity for those remedies which stimulate and give 
strength to these nerve centres. 

The length of blood-wave has reference to that con- 
dition known as "sthenia," an excitation founded on 
strong life. This is especially the case where the wave 
is large in volume, and well supported by the column 
of blood behind. 

The oppressed pulse is marked by a want of power in 
the stroke, and more especially by a feeling as if the 
current in advance of the wave broke its force. Evi- 
dently the blood-Avave does not measure the amount of 
blood passing through the artery. It refers us to ob- 
struction in the capillary vessels, or possibly an impair- 
ment of the large vessels as well, or a wrong in the 
blood unfitting it for circulation. 

If the finger be carefully trained it will notice a vari- 
ation in the surface of the wave, as well as in its length. 
Many times it is distinctly felt as two waves — a first 
sudden and short, and a second full, even and prolonged 
The first may be called the shock-wave, and the secon'i 
the systolic-wave which represents the movement oi 
blood from the heart. 

The shock-wave sharp and pronounced ma}' always be 
referred to undue excitation of the nerves distributed 



STUDY OP DIAGNOSIS. 151 

upon the vessels, and an undue contraction or tension 
of their walls. 

The full, strong, systolic- wave may be referred to ex- 
citation of the heart and strength in its movement. 

The short, systolic-wave evidences a want of cardiac 
power, and especially of impaired innervation from the 
spinal cord and sympathetic. 

The inter-wave current sometimes gives valuable in- 
formation, and it is well for the reader to observe it 
carefully in health and learn its normal condition. 
We find in disease that it has more or less volume, has 
more or less strength, and has more or less of the vibra- 
tile quality. 

When we sj^eak of a full pulse, we have reference to 
the inter-wave current as well as to the wave, and the 
condition of sthenia will be determined by this. It is 
strong life in a state of excitation. 

If now we add hardness, we have added an especial 
lesion of innervation, of excitation steadil} T maintained. 

If we speak of a small pulse hard, we refer it to im- 
pairment of life from activity, still maintained. 

If we have a small pulse soft and easily compressed, 
we refer it to deficient innervation. 

If we have a small pulse vibratile, we say it is the ex- 
pression of impaired life, with great excitation of the 
nCrve centres. 

If we have an empty pulse, the inter-wave current 
hardly perceptible, it is the evidence of impaired life, 
with enfeebled innervation from the sympathetic. 

There are other changes of the pulse which might be 
noticed, but they are difficult to describe and learn. I 
do not think that we can tell every lesion by it, as 
Chinese doctors believe, but to the educated touch it 



152 STUDY OF DIAGNOSIS. 

gives most valuable information with regard to the most 
important functions of life. I doubt not many physi- 
cians can locate lesions with very great certainty from 
it alone; that they can distinguish lesions of the brain, 
lungs, digestive apparatus, urinary apparatus, etc., and 
determine, to some extent, their character. 

But in the practice of medicine, there is something 
of more importance than locating a disease, or even de- 
termining the character of the lesion. The important 
object is to associate the evidences of disease with reme- 
dies for their cure, and to make the expressions of dis- 
ease point to the medicine. 

Feeling the pulse gives us a knowledge of the lesions 
of the circulation — most important information in the 
majority of diseases. Every lesion of the circulation 
is distinctly announced to the cultivated touch, as is 
some lesions of the blood and of the nervous system. 
In so far as we study the pulse. I desire that it shall 
mean special remedies — not names of disease. 

Frequency calls attention to a wrong of the circulation 
and prompts the asking of the question — why? It 
does not necessarily mean Yeratrum, Aconite, Gfelsemi- 
num, etc., though it is suggestive of them Why ? Is the 
wrong in the vessels an obstruction to the free circula- 
tion of blood, requiring an increased movement of the 
heart to compensate it ? Is the wrong an enfeeblement 
of the heart, requiring increased frequency of impulse 
to compensate for want of power? Is the increased 
frequency dependent upon irritation of the cardiac 
plexus? Is the frequency dependent upon a wrong of 
the blood? Upon a cerebro-sj)inal wrong? 

The full pulse with strength means medicine — Yera- 
trum. Whether full and hard, full and bounding:, the 



STUDY OF DIAGNOSIS. 153 

special sedative named is at once suggested. It may 
not be all that the patient wants, but it is one, and in 
many cases will stand first. 

The full pulse doughy (lacks the marked vibration) 
means Lobelia ; or if marked and associated with full- 
ness of mucous membranes and purplish discoloration. 
Baptisia; or if accompanied with muscular pain, Apo- 
cynum. 

The full pulse ope??, is kindly influenced by Podophyl- 
lin, and especially by Quinine in full doses. 

The large pulse empty calls for the alkaline sulphites,. 
Sulphurous Acid, stimulant baths or fatty inunction, 
Quinine, and histogenetie food. The sensation we get 
in this case is of an artery of large calibre, but with too 
little volume of blood — the sensation after the impulse 
being of emptiness. 

The full pulse vibratile calls for Gelseminum, usually 
associated with Yeratrum. . 

The full pulse oppressed, calls for Belladonna, alter- 
nated with Yeratrum ; if sepsis, Baptisia. 

The small pulse usually means Aconite. 

The small pulse vibratile Aconite and Grelseminum. 

The small pulse oppressed Belladonna and Aconite. 

The small, soft, easily compressed pulse. Aconite, 
stimulants. Small doses of Quinine with Opium and 
food. 

The small pulse, frequent, easil} T compressed, the wave 
of blood giving a sense of squareness as it passes under 
the finger, Opium. 

Want of power in the impulse suggests Digitalis, 
Capsicum. 

The sharp stroke of the pulse with tremulous wave be 
tween strokes, means Bhus. 



164 STUDY OP DIAGNOSIS 

The sharp stroke of pulse, with even, small, vibratile 
current between strokes — Bryonia. 

The dull stroke with tremulous or vibratile wave — 
Phytolacca. 

The open, tremulous pulse — Arsenicum. 

The small or open pulse in which the wave of blood 
drops suddenly as it passes the finger — Pulsatilla or 
Cactus. 

Irregularity of pulse, soft or open, with a distinct 
wrong in the stroke — Cactus. 

The steady, vibratile pulse, without marked wave — 
Macrotys. 

We have often reason to believe that Quinine is indi- 
cated by the periodicity of the disease, and yet our ex- 
perience with the remedy raises doubts of whether it 
will be well received and exert a kindly and curative 
action. If the pulse is hard and mbratile, wiry, we will 
not give it; if it is soft and open we ma}' expect its 
kindly action. The physician who would administer 
Opium or its salts with a hard, wiry pulse, would be 
doing his patient a great wrong. Here, also, we want 
a soft, open pulse for the kindly action of the medicine. 
No one in his senses would give Podophyllin when 
there was a small, wiry pulse, or when it had a sharp 
stroke — the patient might get through safely, and it 
might kill him. 

This is only a partial consideration of the subject, 
and the results of my own experience. It should agree 
with what others know of the pulse as a means of 
diagnosis, and I hope will be thoroughly proven. 
Even if proven to be without foundation in fact, the 
investigation will give practical knowledge, and will 
increase our knowledge of the relationship between 
the evidences of disease and remedies. 



STUDY OF DIAGNOSIS. 15*5 

If the reader will notice carefully, be will see a 
marked resemblance between the touch of the pulse, 
and the general sense of touch when the band is applied 
to the skin. The sensation from the slight oedema of 
cellular tissue, that indicates Apoeynum, and the pulse 
that says Apocynum is wonderfully similar. The sen- 
sation from the skin that says Lobelia and the pulse 
that says Lobelia is the same. The pulse of Yeratrum 
is associated with the skin of Yeratrum. And so we 
will find it all the way through, if we see the indica- 
tions for remedies rightly they never conflict. 

THE TEMPEBATUKE. 

Among the evidences of disease, none are more defi- 
nite and important than changes in the temperature. 
Heat is not only force in the animal body, but it is also 
a condition of life; a man has activity through it, and 
he has life b} r it. The theory of Samuel Thomson — 
" Heat is life, cold is death," was very simple, and had 
much of truth in it — it was just one-third of the truth. 
Cold is death, but so is too high a temperature, and an 
unequal distribution of heat. 

The human body maintains its healthy functions at a 
temperature varying from 98° to 98.5°. This is a con- 
dition absolute for health. If the temperature varies 
from this above or below, disease must result. We may 
state the proposition in a different form — no disease 
can exist without changing the temperature of the 
body, either raising it, depressing it, or rendering it 
unequal. Thus, change of temperature becomes an 
absolute evidence of disease, though it may not point 
out the character or the location of the lesion. 



156 



STUDY OF DIAGNOSIS. 



In the olden time changes in the temperature were 
determined by the hand applied to the surface of the 
body. With some physicians the touch would be so 
educated that it would recognize these changes with 
considerable accuracy. Whilst it would not note the 
changes within one or two degrees when the tempera- 
ture was above, it would recognize certain alterations 
of the skin, and modifications of heat or electricity, 
that the body thermometer does not take cognizance 
of. This information is of great importance, and whilst 
we highly value the body thermometer, we purpose to 
cultivate the touch as far as possible. 

The Body Thermometer. — The thermometer is pre- 
sented to us as a new means of diagnosis, but as far 
back as 1754. one hundred and twenty years ago, An- 
tonius De Haen, the first clinical teacher of medicine 
at Yienna, insisted upon its use to determine the tem- 
perature of the body, rather than to judge by the hand. 
But though De Haen showed that it was the only cor- 
rect index of heat, and seemingly indispensable in 
diagnosis, if it was desirable to determine the temper- 
ature, he was not able to convince the profession that 
this was desirable, and its use lapsed with his death. 

The use of the thermometer has been revived within 
the last fifteen years, and is now exciting much attention, 
and is employed by many as a most valued means of 
diagnosis and prognosis. It is valued now, because we 
appreciate the fact that the vital processes can only be 
performed in perfection at the normal temperature of 
98°, and that just in proportion as it varies from this ; 
either above or below, they are changed or arrested. 
Indeed, it would seem, that heat, at this degree, was the 



STUDY OF DIAGNOSIS. 157 

most essential condition of life, and that if there be a 
variation from it, those means which will restore the 
thermal equilibrium are the most direct and important. 

The difficulty in the way of using the thermometer 
to determine the temperature of the body, seemed to 
be in a want of sensitiveness, and precision in marking 
fractions of a degree. This has been overcome by em- 
ploying a large quantit}^ of mercury in the bulb, and a 
short stem graduated from 80° to 115°. By thus in- 
creasing the quantity of mercury, the degree, as marked 
upon the scale, was so lengthened that it could readily 
be divided into fourths, and even eighths or tenths. 
And the sensitiveness to heat was in direct proportion 
to the increased, length of a degree as marked upon the 
scale. 

A registering thermometer is one in which a small por- 
tion of mercury is detached from the main column in 
the stem of the instrument. This detached portion is 
elevated by the expansion of the mercur} 7 below, which 
ascends in the stem below it, and thus marks the degree 
of heat. But it is not influenced by the descent of the 
main column, but remains in its place, thus acting as a 
register. In using this thermometer, the detached por- 
tion of mercury is lowered in the stem below the 
register by giving it three or four gentle taps with the 
hand from below. 

As the instruments require great accuracy in manu- 
facture, they exceed in price the ordinary thermometer. 
Yet very good instruments may be purchased for 
$2.50 to $5.00; the self-registering, in morocco cases, 
1 would recommend as preferable. 

It may be remarked, that we employ thermometers 
graduated to Fahrenheit's scale, but some of the 



168 STUDY OP DIAGNOSIS. 

cheaper German instruments have the scale of Reaumur 
or Centigrade. 

Applying the Thermometer. — The majority of 
writers direct that the thermometer be applied in the 
axillae, as it is there completely enclosed and sur 
rounded by the soft parts. When it is convenient, as 
in some acute diseases, the person being in bed, I think 
the axillae the best, yet there are many cases when we 
should like to test the temperature, that it would be 
very inconvenient for the person to unfasten the clothes 
to reach this part. Women, especially, will object to 
this method of examination. 

To suit these cases, I apply the bulb of the ther- 
mometer under the tongue, having the patient close 
the mouth. This is much more convenient, and so far 
as my experience extends, just as reliable. 

The thermometer should be retained in its place from 
three to five minutes, as it requires this length of time 
for the full influence of the body's heat. It is well 
also, in some cases, to watch the register to see how 
rapidly the mercury rises, as there is much difference 
in this in different cases, and it also becomes an element 
in diagnosis. 

Eanges of Temperature in Health. — The standard 
temperature of the healthy body is 98.5°, and is sub- 
ject to a slight variation during the day of about 0.820°. 
The maximum temperature is in the early morning; it 
fluctuates and gradually decreases during the day, and 
is lowest at midnight. 

" The observations of Drs. Edwards and Davy have 
shown that the amount of animal heat may be consid- 
erably altered by a number of collateral circumstances. 



STUDY OP DIAGNOSIS. 159 

But the great distinction between these alterations of 
temperature in health, and those which are the result 
of disease is, that these variations are generally tempo- 
rary, and Avithin narrow limits — amounting to mere 
fractions of a degree — rarely more than 1.8° Fahr. to 
3.6° Fahr. whereas those which are due to disease are 
persistent so long as the disease exists. 

; ' The following are the collateral circumstances 
which mainly influence animal heat in our daily life, 
and which require to be remembered in order that erro- 
neous conclusions may not be drawn: 1. Active exercise 
[not carried to the extent of exhausting fatigue] raises 
the temperature proportionally to the degree of mus- 
cular exertion made. 2. Exposure to cold without exer- 
cise lowers the temperature. 3. Sustained mental ex- 
ertion reduces temperature about half a degree- 4. The 
amount of heat is also reduced by a fall meal and the 
use of alcohol; but it rises again as digestion advances. 
5. There are diurnal fluctuations capable of being thus 
determined. 6. The temperature of the body rises 
with the temperature of the air ; and sudden transitions 
from a cold to a hot climate induce a feverish state 
marked by increase of temperature on bodily exertion. 
7. The average temperature within the tropics is nearly 
1° Fahr. higher than in temperate regions. 8. The 
temperature is more readily and rapidl} T affected — more 
sensitive, so to speak — than either the pulse or the res- 
piration ; and this is especially the case in disease." — 
Aithen. , 

Eanges of Temperature in Disease. — We have to 
study both an increase and a decrease in the temperature 
of the body, the first being of most common occurrence 



160 STUDY OF DIAGNOSIS. 

and having the greatest range. Thus whilst a decrease 
of but one degree, if maintained for a considerable 
time, will result in death, an increase of two to foui 
degrees ma}' be maintained for a month with safety to 
life. 

The increase of temperature is usually proportionate 
to the frequency of the pulse, one degree corresponding to 
an increase of ten beats per minute. Thus : 

With a temperature of 98° pulse of 60 

" " " 99° " 70 

" " " 100° » 80 

11 ' 101° " 90 

* * « 102° " 1Q0 

1 " " 103° « 110 

" « " 104° " 120 

" " " 105° " 130 

" " " 106° < 140 

This table is for adult males of good development, 
and will not apply to those of feeble constitution, of 
sedentary habits, or of a nervous temperament. In 
such, with a normal temperature of 98°, the pulse would 
be 7G or 80, and the increased frequency to each degree 
would be but six or eight, until the 103° was passed. 

In chronic disease we also find an increase of tem- 
perature, and the thermometer becomes almost as cer- 
tain a means of diagnosis and prognosis as in febrile 
and inflammatory affections. Thus, for instance, in 
phthisis pulmonalis, we find a permanent increase of 
temperature to 99° and 100°. in the first stages, in- 
creasing to 101° and 102°, as the disease progresses. 
This increase is so uniform that it will furnish the best 
evidence of the nature of the disease in its earliest stage. 
The frequency of the pulse corresponds to the increase 



STUDY OP DIAGNOSIS. 161 

of temperature. Breaking down of the tubercles is 
announced by a marked increase of temperature, cor- 
responding to the destruction of king tissue, and the 
danger to life. 

In acute fevers and inflammations, we find the tem- 
perature increasing in the ratio of the severity of the 
disease. It does not, however, remain uniformly the 
same throughout the twenty-four hours, but presents a 
marked morning decline and evening elevation. This 
is very distinct, even in continued fevers, which we are 
accustomed to think of as being uniform in all their 
phenomena. This fluctuation is rarely less than one 
degree, and is frequently two degrees cr more. 

The value of the thermometer, as a means of diag- 
nosis, is thus estimated by Dr. Aitken : 

" In the course of many diseases, whose diagnosis 
has been accurately determined, if the temperature de- 
parts from its normal or typical range, the thermometer 
will furnish the best and the earliest indication of any 
untoward event, such as the additional development of 
disease, or other visceral complications, in its course. 

" When once the typical range of temperature (nor- 
mal, as it were, of the particular disease) is determined, 
a basis is laid for appreciating irregularities or compli- 
cations in its course in particular cases. For example, 
a patient exhibits symptoms of fever of the t}<phoid 
type, but during the progress of the first week his tem- 
perature becomes normal, for however short a space of 
time — the occurrence of this event proves that the fever 
is not what it was supposed to be. Again, a patient 
may suffer from all the general symptoms of incipient 
pneumonia ; but there still is a doubt as to whether in- 
farction of the lung has taken place. The sputa being 
14 



162 STUDY OF DIAGNOSIS. 

suppressed, or not procurable, does not assist the diag- 
nosis. If, however, the temperature is found to be 
normal, it is certain that no croupous exudation has 
taken place in the lung, and that there is no pneumonia. 
Again, if a tuberculous patient has a sudden attack of 
haemoptysis, and if the temperature of his body is 
normal during and subsequent to the attack, no reactive 
pneumonia, nor any exacerbation of the tuberculous 
exudation need be expected. This is a new field open 
for investigation in cases of phthisis. 

" Again : In all cases of convalescence, so long as the 
defervescence proceeds regularly, as measured by the 
temperature, no relapses need be feared ; on the other 
hand, delayed defervescence in pneumonia, the persist- 
ence of a high evening temperature in tj-phus or 
typhoid fever, or the exanthemata, and the incomplete 
attainment of normal temperature in convalescence, 
are signs of great significance. They indicate incom- 
plete recovery, supervention of other diseases, unfavor- 
able changes in the products of disease, or the continu- 
ance of other sources of disturbance requiring to be 
carefully examined into. The onset of even a slight 
elevation of temperature during convalescence is a 
warning to exercise careful watching over the patient, 
and especially for the maintenance of a due control 
over his diet and actions." 

The Influence of Treatment on the Tempera- 
ture. — By reference to table on page 160, it will be 
noticed that there is a constant relation between the 
frequency of the pulse and the temperature: that with 
a range of temperature of 103° to 105°, we find a pulse 
ranging from 110-115 to 130-140. It is evident, there- 



STUDY OF DIAGNOSIS. 163 

fore, that if we have any means that will control the 
circulation — lessening the frequency of the pulse — it 
will also lower the temperature. 

The question then arises, if a treatment will thus 
control the pulse and temperature, ma}' it not change a 
severe and dangerous case into a mild one without 
danger? We answer this question in the affirmative, 
not as a theory, but from observations on many cases 
of disease. 

I think I am justified in stating, as an axiom, that 
just in the ratio that the circulation is thus controlled, 
and the temperature reduced, the fever is rendered 
mild. 

I wish it distinctly understood, however, that I refer 
onl}' to those influences which can be continued for 
some days, and not to those which endure but a few 
hours. The use of large doses of Veratrum will bring 
down the pulse from 120 to 60 or 70 beats per minute, 
in six to ten hours, and with a corresponding reduction 
in temperature; but it is not possible to continue this 
influence, as in a few hours the stomach becomes irri- 
table and rejects it, or the depression of the sympathetic 
nervous system is such as to peril life. 

But if the remedy is given in doses of half to one 
drop, sedation is slowl}' produced, the stomach receives 
it kindly, and instead of depression of the vegetative 
functions, the remed}' acts as a stimulant to them. 

But is it possible to arrest a fever before it has run its 
course? I am satisfied that this question may also be 
answered in the affirmative. Not that every case can 
be shortened, for in some the local lesion of Pe3^er's 
glands proves an insurmountable obstacle ; but many 
can be arrested from the seventh to the ninth day, more 



164 STUDY OF DIAGNOSIS. 

by the fourteenth, and in nearly all the disease can be 
restricted to twenty one days. 

A fever terminates naturally — by a decrease in the 
frequency of the pulse, a diminution of the tempera- 
ture, and the re-establishment of secretion, by which 
the cause of the disease is removed. If, then, by the 
use of sedatives, we lessen the frequency of the pulse, 
and obtain an equal and uniform circulation, with a 
corresponding decline in temperature, we find it easy 
to establish secretion from the skin, kidneys and 
bowels, by the usual means. And in a majority of 
cases these processes may be sustained by the use of 
nutritious food, and the use of small doses of the Bitter 
Tonics. 

But the question arises, does the temperature bear 
the same relation in chronic disease, and will treatment 
influencing the temperature have a like curative influ- 
ence? I answer the question in the affirmative, and 
adduce as an example phthisis pulmonalis, one of the 
most intractable diseases we have to contend with. 

In this, so long as the increased temperature is main- 
tained, the disease progresses ; and very frequently its 
rapidity is in exact ratio to this. Diminish the temper- 
ature, and the disease progresses more slowly Reduce 
it to 98.5°, and maintain it at this, and the patient re- 
covers. 

The wrong of temperature is but the expression of 
disease. If the disease is favorably influenced by rem- 
edies the temperature falls or rises towards the normal 
standard. Thus in a given case of disease we may see 
the pathological wrong, whether of the blood, the 
nervous system, or of waste and excretion, and at the 
same time the indications for the remedy which will 



STUDY OF DIAGNOSIS. 165 

right the lesion, and we know that its use will reduce 
the temperature. Thus in a case of zymotic fever the 
evidences of sepsis are marked, and with sepsis there 
must be an exalted temperature. If now we select the 
right antiseptic, say Sulphite of Soda, Chlorate of 
Potash or Baptisia, the temperature will fall with its 
use. If in any given case we have a special indication 
for Nitric Acid, for Podophyllin, Quinine, etc., they 
will influence the temperature toward the normal 
standard. 

But in many cases the wrong of temperature ma}^ be 
regarded rather as a cause than as a result. If the 
temperature is above the normal standard the functions 
of life are impaired in the ratio of the excess. Thus as 
we have already seen — increase of temperature is asso- 
ciated with acceleration of the pulse — increase of tem- 
perature is associated with frequent respiration. With 
an increase of temperature there is an arrest of diges- 
tion, blood-making, nutrition, waste, retrograde meta- 
morphosis, and secretion from skin, kidnej^s and bowels. 
We also find that structural lesions are influenced in 
the same manner. Inflammation is active in propor- 
tion to increased temperature, as is also the tendency 
to suppuration and death of the part. The influence 
of zymotic causes of disease is also increased in tho 
ratio of increase of temperature, and the condition 
known as typhoid is marked in proportion to it. In 
surgical disease we find the processes of repair arrested 
when the thermometer marks 103° ; above this the pus 
loses its laudable character, becomes thin, ichorous, 
etc., and presently the structures soften and break 
down. 

The fact that increase of temperature is a condition 



166 STUDY OP DIAGNOSIS. 

in many chronic diseases has already been noticed. In 
phthisis pulinonalis the first advent of disease is an- 
nounced by a temperature of 100°. In morbus coxa- 
rius, white swelling, etc., increase of temperature is 
one of the most pronounced and distinctive symptoms. 
In all these cases Ave may say that the rapidity of dis- 
ease is in the ratio of increased temperature, and so 
long as the temperature is thus high no amendment 
need be expected. If the temperature can be reduced 
and maintained at or near the normal standard, the de- 
structive processes are less active, and a cure rendered 
possible. 

If we decide that a wrong of the temperature is a 
cause rather than a result, even though but in part, we 
wish to know the means by which it may be rectified. 
The first proposition — " as is the pulse so is the tem- 
perature " — gives us the use of the very important 
class of remedies — the special sedatives. If these rem- 
edies exert a direct influence in giving a slower and 
better circulation, they will also lessen the temperature. 
Certain remedies especially influence the temperature 
through the nervous system, as Rhus, Grelseminum, 
Bryonia, Belladonna, Nux, Nitric Acid. Others influ- 
ence it through the constitution of the blood, as alka- 
lies, acids, food, etc. 

Then again we look to the skin as the regulator of 
heat in the body. It is possible that a wrong in the 
condition of this apparatus is the cause, in whole or 
part, of this lesion. What is the condition of the skin? 
Is it dry, constricted, full, relaxed? What remedies, 
in the form of baths, or otherwise, will right these 
wrongs ? 

If we take the simple lesion of excess of temperature 



STUDY OF DIAGNOSIS 167 

and frequency of pulse, as seen in febrieula, we will 
find a cure in the cold wet-sheet pack, as we would in 
the early stages of a sthenic inflammation. Or in place 
of this the ordinary vapor bath or spirit-vapor bath 
might be employed. In many cases with a dry and 
constricted skin the sponge baths are found to place 
this organism in better condition, and lessen the tem- 
perature. 

If a bath is medicated, we select it as we would the 
internal remedy. If an alkali is indicated internally 
by pallid mucous membranes, it will be found best for a 
bath. If an acid is indicated internally by deep colora- 
tion of mucous membranes, we will employ an acid 
bath. If the skin is relaxed and enfeebled, we think 
of stimulant, tonic, or astringent baths. We employ 
fatty inunction in two conditions — when the skin is dry 
and constricted, and when it is relaxed and enfeebled — 
in both the inunction answers a good purpose. In 
some cases we combine with it a stimulant, or one of 
the essential oils; in others we make it a vehicle for the 
topical application of Quinine. 

If the increase of temperature is associated with 
waste of tissue, we find it important to provide a better 
fuel for burning, and thus allay the excitation caused 
by destruction of tissue. Thus in chronic disease we 
think of Cod Oil, and foods that contain calorifacient 
material in excess, and that are at the same time easily 
digested. In acute disease we furnish similar kinds of 
food, whilst at the same time we modify the process of 
combustion as much as possible. 

In depression of temperature we find every function 
of life impaired, but in this case the lesion is always of 
depression, whilst in the preceding it was most fre- 



168 STUDY OF DIAGNOSIS. 

quently of excitation. It requires but a slight fall of 
temperature to impair and finally arrest functional ac« 
tivity. With a depression of a single degree a man ia 
sick, and if this is maintained death will result in from 
two or three days to a week. 

In some cases of chronic disease we find a slight de- 
pression of temperature, as a part of the lesion.' At 
once we ask the question, what is the cause ? Is it de- 
pendent upon want of food, or of proper food? A 
wrong of digestion ? An impairment of the respiratory 
function, and of the burning ? Or a wrong of the skin,, 
so that it permits a rapid escape of heat? On the 
answer obtained to these questions, will depend the 
treatment. 

If it is a want of food, or of calorifacient food, a right 
treatment will look to the selection of appropriate 
kinds. If we find a lesion of digestion, either buccal, 
stomachic, or intestinal, means to rectify these lesions 
will be demanded. If it arises from deficient respira- 
tion, we will direct such exercise as will call into activ- 
ity the respiratory function, and facilitate combustion. 
It is possible there may be a defect in certain materials 
that favor combustion. Thus in some cases I have 
found the want to be of Phosphorus, and its administra- 
tion at once restored the calorific function. In others 
it may be of Sulphur, or of Soda, or in some cases it 
would be met by Cod-Oil. Wrongs of the skin, per- 
mitting the escape of heat, are readily recognized by 
the touch, as evidences of relaxation, of exudation of 
water from the blood, or hyper-activity of the sudori- 
ferous glands. The remedies will consist of stimulant 
and tonic baths, or sometimes the use of fatt}' inunction 
with stimulants or with Quiuine. 



STUDY OP DIAGNOSIS. 169 

- An irregular or unequal distribution of heat is a 
source of trouble as well as its increase or diminution. 
If we have too much heat in one place and too little in 
another, we will find associate wrongs of circulation and 
innervation, and there will be impairment of digestion, 
blood-making, nutrition, waste, retrograde metamor- 
phosis, and excretion. Wrongs of the blood are like- 
wise increased, and there is the tendency to deposits of 
imperfectly formed albuminoid material. Local dis- 
eases are also more severe, and the tendency to struc- 
tural changes more marked. 

In chronic disease we will frequently find that no im- 
provement takes place until the wrong of temperature 
is rectified. G-etting well may hinge on getting the 
feet warm. With cold feet, remedies which seem 
adapted to the case, continually fail ; warm the feet, 
even by sprinkling Capsicum in the stockings, and the 
patient improves at once. In some of these cases topi- 
cal means will be all-sufficient, but in others we will 
have to employ such as give strength to the circulation 
and improve innervation. 

In acute disease unequal temperature is one of the 
most unpleasant symptoms met with, and it is always 
looked for in the advanced stages of severe disease. 
The experienced physician examines the patient's toes, 
his knees, his ears, the tips of his fingers, with as much 
interest, as he examines the pulse. If he finds coldness 
of these parts, he is at once awake to the necessity of 
every means for the conservation of life, whether it 
has reference to means to prevent undue expenditure, 
or such as will increase the forces of the body. Cold- 
ness of parts distant from the heart at once suggests 
the idea of alcoholic stimulants as food, to be supple- 
15 



170 STUDY OF DIAGNOSIS 

mented, as soon as may be by such foods as seem best 
adapted to the case. 

Changes of kind in temperature will not be recog 
nized by the thermometer, and hardly by the physiciai 
who prides himself on being "scientific." " Kinds of 
heat indeed ! there is but one heat, and it is nonsense tc 
try to make a distinction in kind " (?) This is all very 
well, but the practiced physician knows that there are 
kinds, at least in so far as his sensations are concerned, 
and that these "kinds " tell him o£ definite lesions, 
and point to remedies. We do not know just why we 
have varying sensations of kind, but we do even in 
warming apparatus. The sensation of heat is not the 
same from a coal stove, an open fire, hot water pipes, 
or a Dutch earthen-ware oven. And the sensation of 
heat by the hand is not the same in simple febricula, 
remittent fever, typhoid, typhus, yellow fever, scarlet 
fever, etc. The kind is unmistakable, and becomes 
more and more so as the wrong oi the blood and of the 
nervous system increases. 

If one applies the hand upon a surface from which a 
sinapism has been recently removed, a peculiar sense 
of "pungency" is experienced. Quite as distinct a 
sensation comes in severe scarlet fever, in malignant 
rubeola, and in diseases characterized b}~the symptoms 
known as typhoid. We get a similar pungent heat 
when there is great excitation of the sympathetic and 
spinal nervous systems. We may say then, that this 
character — pungent heat — which is so readily recog- 
nized by most persons, refers us to lesions of the blood — 
sepsis, and to lesions of the nerve centres — excitation. 
We at once think of antiseptics as appropriate reme- 
dies, and select the particular one by sj^mptoms already 



STUDY OF DIAGNOSIS. 171 

named. In so far as the nervous lesion is concerned, 
we will be guided in the selection of remedies by the 
facial expression and by the pulse. 

Tt is possible many times, to determine the character 
of a local lesion by the sensation given the hand. Thus 
one very readily recognizes the peculiar pungent heat 
of erysipelas, and sometimes the touch will determine 
the advent of this lesion in surgical disease before the 
eye would recognize the change of color, or the intu- 
mescence of tissue. The hand placed upon the abdo- 
men will feel the advent of puerperal inflammation 
before it will be recognized by ordinary symptoms. 
There is very much to be learned in this regard, and it 
is well to give it thought and experiment. 



DIAGNOSIS BY THE EAE. 

The ear may not be as important in diagnosis as the 
eye or touch, yet we purpose employing it to its fullest 
capacity. To the routine physician who asks questions 
and depends for his knowledge of disease upon what 
the patient tells him, it is the organ of greatest impor- 
tance. But we have already seen that we do best when 
we stud}^ disease with our senses, and depend but little 
upon what the patient says. 

If the reader will refer back to our study of facial 
expression, he will notice the statement that wrongs of 
life find expression through the usual channels of ex- 
pression ; where the nerve currents have been most in 
the habit of flowing in health, they incline to flow in 
disease. Mankind use the facial muscles to express 
their feelings or sensations, and hence disease is ex 



172 STUDY OF DIAGNOSIS. 

pressed in the face. For the same reason we should 
expect to find wrongs of life expressed in the voice, in 
all animals using the voice, and especially in man who 
finds it a principal instrument of expression.* 

*The character of the human voice, under the influence of 
various emotions, has been discussed by Mr. Herbert Spencer in 
his interesting essay on Music. He clearly shows that the voice 
alters much under different conditions, in loudness and in quality, 
that is, in resonance and timbre, in pitch and intervals. jSTo one 
can listen to an eloquent orator or preacher, or to a man calling 
angrily to another, or to one expressing astonishment, without 
being struck with the truth of Mr. Spencer's remarks. It is 
curious how early in life the modulation of the voice becomes ex- 
pressive. With one of my children, under the age of two years, 
I clearly perceived that his humph of assent was rendered by a 
slight modulation strongly emphatic; and that by a peculiar 
whine his negative expressed obstinate determination. Mr. 
Spencer further shows that emotional speech, in all the above 
respects is intimately related to vocal music, and consequently to 
instrumental music; and he attempts to explain the character- 
istic qualities of both on physiological grounds, — namely, on 
"the general law that a feeling is a stimulus to muscular action." 
It may be admitted that the voice is affected through this law ; 
but the explanation appears to me too general and vague to 
throw much light on the various differences, with the exception 
of that of loudness, between ordinary speech and emotional 
speech, or singing. 

That the pitch of the voice bears some relation to certain 
states of feeling is tolerably clear. A person gently complaining 
of ill-treatment, or slightly suffering, almost always speaks in a 
high-pitched voice. Dogs, when a little impatient, often make a 
high piping note through their noses, which at once strikes us 
as plaintive, but how difficult it is to know whether the sound is 
essentially plaintive, or only appears so in this particular case, 
from our having learnt by experience what it means! Kcngger 
states that the monkeys ( Cebus azarce), which he kept in Para- 



STUDY OF DIAGNOSIS. 173 

As we come into the sick room we give attention to 
the voice of the sick person, quite as much as we do to 
what he is saying. We find that it expresses strength 
and weakness, is tree or difficult from local disease, and 
shadows forth the condition of the brain in its tone, 
which varies from the listlessness of atony to the quer- 
ulousness of excited feebleness, and the excitation of 
over activity. 

In studying the voice as the expression of disease, 
we recognize its three-fold bearing as it refers us to a 
general impairment of life, a lesion of the brain, and 
to lesions of the respiratory asparatus. If we did not 
keep these sources of wrong in view we might make 
serious mistakes. If, for instance, we have feebleness 
of voice, it may be due to general impairment of life, 
to impairment of the functions of the brain, to deficient 
innervation from the spinal cord, or to a lesion of the 
respiratory apparatus. 

"Whilst strength of voice is usually regarded as evi- 
dence of good vital power, and a good respiratory ap- 
paratus, it will not do to place too much dependence 

guay, expressed astonishment by a half-piping, half-snarling 
noise; anger or impatience, by repeating the sound hu hum a 
deeper, grunting voice; and fright or pain, by shrill screams* 
On the other hand, with mankind, deep groans and high piercing 
screams equally express an agony of pain. Laughter may be 
either high or low; so that, with adult men, as Haller long ago 
remarked, the sound partakes of the character of the vowels (as 
pronounced in German) and A ; whilst with children and 
women, it has more of the character of E and /; and these 
latter vowel-sounds naturally have, as Helmholz has shown^ % 
higher pitch than the former; yet both tones of laughter equally 
express enjoymeni or amusement. — Darwin. 



174 STUDY OF DIAGNOSIS. 

upon it in these regards. It certainly evidences good 
innervation from the brain and spinal cord. But if 
these nerve centres are sound, active, and well supplied 
with blood, we may have a strong voice, even though 
the body at large is nearly exhausted. Usually it is a 
favorable symptom.. 

Feebleness, on the contrary, evidences a lesion of atony, 
either of the body at large, of the brain or mind, of the 
spinal cord, or of the respiratory apparatus. Whilst 
the probabilities are in favor of its being a nervous 
lesion, we will not take it for granted, but make such 
examinations as will localize the lesion. Feebleness 
simply, without querulousness, suggests the use of 
Phosphorus, the Hypophosphites, Cod Oil, Alcohol as 
food, Iron, Arsenic, Quinine. If it is associated with a 
marked effort from the will, and a sighing respiration, 
we refer it to deficient innervation from the spinal cord, 
and think of Strychnia, Ergot, or Santonine as reme- 
dies. In lesion of the respiratory apparatus there will 
be change in the voice other than feebleness. 

It is difficult to give a name to the peculiar expres- 
sion of voice associated with nervous irritation and vas- 
cular excitement, yet the reader will learn to recog- 
nize it readily, and may frequently be able to deter- 
mine these characters of disease by simply hearing the 
patient speak. There is a sharpness, and want of 
smoothness, representing pretty accurately in degree 
the amount of disease. 

The halting voice, evidencing a labored action of the 
brain, tells the story of congestion, and suggests the 
use of Belladonna, or if markedly halting, of Lobelia. 

The oppressed voice, hollow and unsteady, evidences 
a general impairment of life, and calls for stimulants, 
tonics and food. 



STUDY OF DIAGNOSIS. 175 

The oppressed voice from the upper part of the lungs 
suggests deficient innervation to heart and respiratory 
apparatus, and causes us to think of stimulant doses of 
Lobelia. 

Sharpness of voice suggests nervous excitation, and 
will sometimes point to the remedy, as in the peculiar 
sharp accentuation of the Ehus voice, resembling the 
cry enrephalique of the child. 

The cry of the child will frequently inform the phy- 
sician of the location and character of the disease. Of 
course we recognize the fact that there ma}' be but 
little change in the cry, or that there may be changes 
without corresponding disease, but we have other 
means of diagnosis to supplement this, and prevent 
error. Physicians who have given this subject atten- 
tion will recall the peculiar cry of abdominal distress, 
the change which marks disease of the respiratory ap- 
paratus, the oppressed cr} T of congestion, the shrill, 
metallic cry of inflammation of the brain, etc. It does 
not take much observation to distinguish the cry of 
disease from the cry of hunger, or anger. 

In the preceding paragraph a peculiar cr} T , encepha- 
Uque, was noticed, which is so distinctive that it will 
never be mistaken. Its suddenness and shrillness is 
characteristic. In its slighter forms it arises from cere- 
bral irritation and determination of blood, and calls for 
Gelseminum as the remedy. When marked and shrill, 
I should always think of Ehus Toxicodendron as the 
remedy. 

A sudden cry, followed by sobbing respiration, is a 
prominent indication for Bromide of Ammonium. 

The voice is the function of the larynx, and its 
changes will point us to disease of this organ. The 



176 STUDY OF DIAGNOSIS. 

croupous cry and voice is quite as distinctive as the 
croupous cough. If it evidences moisture, we have 
mucous croup; if it is dry and metallic, pseudo-mem- 
branous croup; if variable in tone and character, spas- 
modic croup. 

In chronic disease of the larynx, roughness of the 
voice is one of the first symptoms. As the disease pro- 
gresses, we have various changes in the voice and dif- 
ficult use of it, as characteristic symptoms. 

In chronic bronchitis we also find change, but not 
similar in kind. It may give the voice shrillness, as 
in irritative bronchitis, or dullness, hollowness, or rever- 
beration, as in asthenic bronchitis. 

Cough. — Whilst cough calls our attention to a prob- 
able disease of the respiratory apparatus it does not in- 
dicate with any certainty the character of the disease. 
But even to this extent it is important, for it is possible 
to overlook local disease, from the prominence of gen- 
eral symptoms. 

Whilst cough is usually the expression of disease of 
the respiratory apparatus, it ma} r have its origin in 
other diseases. Thus we find cough from gastric, 
biliary and intestinal lesions, and from disease of 
the nerve centres, and our examination is made with 
reference to these probable causes in obscure cases. 

Cough is the expression of irritation, and comes from 
the sense of an irritant material in the respiratory pas- 
sages, which it is intended to remove. But many times 
there is nothing to be removed — it is a misconception 
of the respiratory nerves, which suffer from irritation, 
and we wish to determine whether or not the effort is 
to be favored. In the larger number of cases expecto- 



STUDY OF DIAGNOSIS. 177 

ration is undesirable, and if we remove the irritation 
of the nerves the congh ceases. 

A little attention upon the part of the physician will 
determine this point, as it is quite easy to distinguish 
the cough necessitated by increased secretion, and at- 
tended by expectoration, from the inefficient, rasping 
cough of irritation. In either case, but especially in 
the last, an effort of the will is of marked benefit in 
checking cough. 

The character of the cough expresses to some extent 
the condition of the respiratory passages. If dry, 
ringing, metallic, we think of irritation, determination 
of blood, and arrest of secretion, and the remedies at 
once suggested are those which allay irritation, check 
determination of blood, and favor normal secretion. 
If moist, rattling, gurgling, dull, stimulants to the res- 
piratory passages, as well as remedies to relieve irrita- 
tion are suggested. 

A cough is more or less forcible, and more or less 
easily under the control of the patient. If forcible, 
not under control, or explosive, we at once suspect a 
wrong of the nerve centres, usually of the basilar brain, 
and select remedies accordingly. Of course we may 
have sUch uncontrollable cough from local irritation, 
especially of the throat, but this will be readily recog- 
nized b} 7 the expression, as well as from the patient's 
sensations. 

A cough has more or less evidence of strength, both 
of the respiratory apparatus, and of the body at large. 
The strong, well sustained cough may be a source of 
annoyance, but evidences good vitality and a naturally 
good condition of the respiratory organs. A feeble 
cough, on the contrary, is the evidence of debility, and 



178 STUDY OF DIAGNOSIS. 

at once suggests the necessity of care in the conserva- 
tion of life, and the employment of means which will 
give strength, especially the selection of proper foods. 
A cough maj^ be feeble from deficient spinal innerva- 
tion, and spinal stimulants would prove the best reme- 
dies. 

Coughs are spoken of as short, hacking, deep, bron- 
chial, etc., and these characteristics may suggest the 
locality of disease. A short cough may arise from dis- 
ease of the upper lobes of the lungs, or it may be due 
to disease of the parenchyma of the lung, as in the 
first stage of a pneumonia. The hacking cough evi- 
dences irritation of the respiratory nerves pointing 
in the throat. The deep or bronchial cough is at once 
referred to lesions of the bronchial tubes, though it is 
not as good evidence as we would wish. 

A cough niaj have its origin in irritation of any part 
of the respiratory apparatus, from the pharynx, larynx, 
trachea, bronchial tubes, parenchyma of lungs, to the 
pleura. As named above, its character may suggest the 
seat of disease, but as a rule, it is not definite. A sin- 
gular thing about coughs is, that the irritation points 
so that many times the patient can localize the sensa- 
tion of irritation for us. Cough very frequently points 
in the pharynx, and the irritation of the throat seems 
to be its direct cause ; such a cough is based to a con- 
siderable extent upon irritation of the respiratory 
nerves, and remedies directed to relieve this will be the 
best cough medicines. In other cases cough points 
about the supra-sternal notch, and if very severe and 
persistent suggests the use of remedies which influence 
the sympathetic nervous system, as Veratrum, Bryonia, 
Cactus, Pulsatilla. 



STUDY OF DIAGNOSIS. 179 

Coughs may be spasmodic and paroxysmal, even in 
severe cases, showing distinct, epileptiform symptoms. 
Whooping cough is the typical spasmodic cough, but 
we have in the cough of measles, and some diseases of 
the respiratory apparatus, the same characteristics. It 
suggests Drosera, Belladonna, and Bromide of Ammo- 
nium. 

PHYSICAL DIAGNOSIS. 

Diseases of the respiratory organs and the heart are 
diagnosed in part by an exploration of the chest with 
the ear. Whilst an examination of the chest with the 
eye and the touch will determine something of the 
character of disease, and direct our attention to reme- 
dies, our reliance will be placed principally upon what 
we hear. 

In the case of the respiratory organs, a very import- 
ant part is to determine the capacity of the lung for 
air, or the amount of air contained in the chest, and 
this is accomplished by percussion. The walls of the 
chest are thin and elastic, whilst the lung which fills it 
contains normally four or five times as much air as 
there is of solid substance. Any elastic body^contain- 
ing air will give resonance when struck, and the reso- 
nance will be in proportion to the amount of air. 
Lessen the amount of air, replacing it with a solid or 
fluid, and dullness of sound is the result. 

The object of percussion then, in diseases of the re- 
spiratory organs, is to determine the condition of the 
parenchyma of the lungs with reference to capacity for 
air. By examination of the healthy thorax we obtain 
a standard of normal resonance for different parts of 



180 STUDY OF DIAGNOSIS. 

the chest, and this we use as a basis for comparison. 
In many cases, but one side of the thorax being in- 
volved in disease, a comparison is instituted between 
the sound and the diseased side. In such cases, of 
course the information is more accurate, as we have the 
normal standard of resonance before us. 

Percussion is either direct or mediate, as we strike 
directly upon the wall of the chest, or interpose some- 
thing between. Direct percussion may sometimes be 
employed Avith advantage, using one or two fingers to 
give the blow. The only objection to this method is 
the unpleasantness to the patient, and the difficulty of 
making percussion of the intercostal spaces. In medi- 
ate percussion an ivory or rubber plate (pleximeter) is 
sometimes employed, using the finger for the stroke, or 
a small mallet of similar materials. The best method, 
however, is to apply one or two fingers accurately to 
the wall of the chest, and use the middle finger, sup- 
ported by the ring finger and thumb to give the stroke. 
It is necessary to use care in this, the fingers of the one 
hand being accurately applied to the chest, and the 
stroke being at right angles, and the muscles of the 
hand held firmly so as to give a quick rebound. 

As the object to be determined is the capacity of the 
lung for air. we make percussion both during full in- 
spiration and after expiration. In examining the mar- 
gin of the lungs over the false ribs and the sternum, it 
is necessary to have the patient take a full inspiration 
to carry the lung down to the insertion of the diaphragm 
in the one case, and to the mesial line in the other. In 
making percussion over muscles it is well to put the 
body in such position that the muscles will be rendered 
tense. In examinations about the shoulder, it is raised 



STUDY OF DIAGNOSIS. 181 

to allow our examinations to be carried up in the 
axillaiy space, or thrown forward or backward, to 
enable us to reach the upper part of the chest. 

In making comparison between the two sides, we are 
careful that there is the same degree of inflation, and it 
is better to have the patient take a full breath, and hold 
it as long as he can conveniently, or cease respiration 
for a moment, after the air is thrown out. 

Normal resonance tells us that the parenchyma of 
the lung is free from effusion, it may be the seat of irri- 
tation, but the capacity for air is not interfered with. 

Increased resonance in slight degree is heard when 
the function of one lung being impaired, the other does 
an increased work. In greater degree it is the evidence 
of emphysema. When very marked, and over a lim- 
ited portion, it is the evidence of a cavity. 

Dullness on percussion evidences that the air is re- 
placed by a solid or fluid ; as is the degree of dullness, 
so is this change in the physical condition of the lung. 
We have dullness in acute pneumonia commencing 
about the third day, sometimes earlier, and increasing 
as deposit takes place in the air cells and intercellular 
passages, and in the connective tissue — as is the dull- 
ness, so is the intensity of the disease. Resonance returns 
when the circulation is restored, and effused materials 
are absorbed. Dullness is also an evidence Of chronic 
inflammation of the lungs, being usualty much more 
extensive than in phthisis pulmonalis, for which it 
might be mistaken. Dullness on percussion is heard 
in phthisis, when the tubercle is deposited in consider- 
able quantity and near the surface. In the earlier 
stages the dullness is so slight that it is not an import- 
ant evidence of disease. 



IW 



182 STUDY OF DIAGNOSIS. 

We have dullness on percussion where there is fluid 
in the pleural cavities, whether it is simply of water, or 
the products of inflammation. In this case the dullness 
is of the most dependent part, and unless it is an ex- 
treme case, changing the position of patient, will change 
the situation of the dullness. 

We have dullness on percussion in hvdropericardium, 
and to a limited extent in hypertrophy of the heart. 
The situation of the dullness, and the change in the 
sounds from the heart, will determine the condition of 
disease. 

Occasionally we have dullness on percussion from the 
formation of a thoracic aneurism, and still more rarely 
from growths in the cavity of the chest. Other 8} T mp 
toms will determine the character of the wrong. 

The reader will notice that in acute disease dullness 
on percussion has reference mostly to effusion into, and 
solidification of the parenchyma of the lung. The ex- 
tent of the dullness determines the amount of tissue 
involved, and its intensity determines, to some extent, 
the severity of the lesion. In so far as it suggests 
treatment, it would say — lessen irritation and determi- 
nation of blood to the lungs — give the respiratoiy appa- 
ratus rest — by appropriate food, and in so far as medi- 
cines act to sustain the life of the part, and of the body at 
large — and by the establishment of secretion, promote 
the absorption of the effused material. 

Percussion is sometimes employed in other parts than 
the thorax to give evidence of disease Thus we find 
that some wrongs of the stomach, of the liver, spleen, 
bowels, and reproductive apparatus', give rise to 
changes in the sound? heard on percussion. 

Disease of the stomach with generation of gas, will 



STUDY OF DIAGNOSIS. 183 

be evidenced by marked resonance on percussion over 
the stomach. In some cases of chronic disease, this 
condition is persistent, and the continually distended 
stomach is pressed upwards until it occupies consider- 
able space, and resonance might lead us to suppose that 
a cavity had formed in the inferior lobe of the lung, 
had we not symptoms of gastric lesion, and the reso- 
nance extending across the epigastrium. 

On the right side an enlarged liver pressed upwards 
encroaches upon the cavity of the chest, and viws 
marked dullness on percussion over the right false ribs. 
The evidences of wrong digestion, and the fullness at 
the margin of the ribs will correct the diagnosis. 

In distension of the bowels by gas, we get the evi- 
dence of resonance on percussion. If of the small in- 
testine it occupies the anterior part of the abdomen ; if 
of the large intestine it is lateral, or in the situation of 
the transverse colon. 

In ascites the small intestine distended with gas floats 
at the top, and though we get the dullness of water 
below, and succussion on palpation, there is resonance 
at the highest part, if the convolutions are free to 
move. 

In ovarian dropsy, on the contrary, the sac displaces 
the small intestine as it grows, and either crowds it 
upward or backward. Intestinal resonance on the 
surface, in dropsy, is therefore one of the differential 
points in distinguishing between ovarian disease and 
ascites. 

We employ palpation to determine the presence of 
fluid, whether in the cavities, or formed by the break- 
ing down of tissue. In some cases the evidence of 
fluctuation is very distinct, the wave of fluid passing 



184 STUDY OF DIAGNOSIS. 

distinctly from the hand on the one side, to the hand 
on the other. In other cases, we only obtain a sense 
of mobility and the elasticity of fluid. 

When parts give rise to sound in the performance of 
their functions, the character of this becomes evidence 
of disease. This is the case with the respiratory appa- 
ratus, the heart, and to a less extent with some other 
parts. 

Listening to sounds thus produced is called ausculta- 
tion, and as practiced may be either direct or mediate. 
In direct auscultation, the ear is applied to the part, 
and the sounds heard. In mediate auscultation, an 
instrument called a stethoscope is employed as a con- 
ductor of sound. 

I prefer direct auscultation, as we desire to hear the 
exact sounds produced, neither intensified nor modified. 
It is quite as easy to apply the ear as a stethoscope, 
and except in some rare cases of cutaneous disease 
there is nothing objectionable in such examination. 
It is claimed that female modesty might be shocked by 
this direct examination, both of the chest, and especially 
of the lower abdomen to detect the beatings of the 
foetal heart. But 1 confess that in my professional life 
I have met with but little,of this mock modesty. 

The special value of the stethoscope is the impression 
it makes upon the public. In the olden time the phy- 
sician carried a gold or ivory headed cane, or rather 
a staff, to give him an appearance of dignit} 7 , and the 
professional pose, as shown by Hogarth, Avith the head 
of the cane pressed against the nose or forehead, in 
profound thought, is a fair representation of the dig- 
nity " that £>«j/s." As the physician's cane has gone 
out of fashion, the stethoscope, and instruments of 



STUDY OF DIAGNOSIS. 185 

similar kind came in to sustain the, dignity of the pro- 
fession. 

Stethoscopes are made in varied forms, from the sim- 
ple short wooden cylinder (with a hole through it) to 
the double ear-tube instrument of Camman. Some are 
so illy adapted to their use, that scarcely anything can 
be heard, except the unpleasant roaring from ill adap- 
tation to the ear. The best stethoscope is a simple 
cylinder of solid wood, with the one end adapted to the 
walls of the chest, and the other to the physician's ear. 
It may be long or short, or have any shape the taste 
of the maker may give it, if it possess the characters 
named, it will answer its purpose well. 

In the practice of auscultation, whether direct or 
with a stethoscope, the physician is careful to avoid 
adventitious sounds, and to place his bodj 7 in a conve- 
nient position for listening. The rubbing of clothing, 
either upon itself, or against a stethoscope, will fre- 
quently mask the sounds we wish to hear. A con- 
strained position of body frequently interferes with 
listening. 

In auscultation of the chest in health two respiratory 
sounds are heard — the respiratory murmur, and the 
bronchial sound. The first is heard during inspiration 
and expiration over the entire surface of lung; the 
second is heard by applying the ear over the spinal 
column from the middle cervical region to the sixth 
dorsal vertebra — the spinal column being a good con- 
ductor of sound. If the normal respiratory murmur 
is heard we know this portion of the parenchyma of 
lung is healthy ; if it is changed in character, or re- 
placed by adventitious sounds from the air cells and 
small passages, we know that there is disease. 



186 STUDY OF DIAGNOSIS. 

In studying auscultation, it is well to study in the 
language most familiar to us. If we are original 
Romans we may pursue the study in Latin ; if French, 
we may use French technical terms; but if English is 
our mother tongue, we had better employ English, and 
use words with especial reference to their meaning. I 
think it is possible to so classify and name the morbid 
sounds that the reader can learn them without trouble. 

We may say first, that a wrong sound made in the 
respiratory apparatus is evidence of disease of this 
apparatus. We want then to determine the value of 
the sound, and the distinct lesion that produces it. 

To this end, the first question is as regards the 
medium for the conduction of sound. Solids conduct 
sound best, fluids next best. Air stands next as a con- 
ductor, and mixed bodies last. The lung, with its 
spongy tissue filled with air is a bad conductor of 
sound. If it is solidified, it becomes a good conductor, 
and sounds will be heard, which otherwise would not 
reach the ear. Fluids compressing the lung are also 
good conductors of sound. To determine this point, 
then, percussion is made — if there is resonance the 
sound is referred wholly to a wrong of the part where 
it is produced ; if there is dullness on percussion, it is 
referred in considerable part to the consolidation of 
lung, or to the effusion, which gives a better conductor 
of sound. 

Morbid sounds may be divided first into blowing and 
crepitant, having reference to the parts in which they 
are produced. Blowing sounds are produced in bron- 
chial tubes, and crepitant sounds in the intercellular 
passages and air cells. 

Blowing sounds are blowing. The idea the listener 



STUDY OF DIAGNOSIS. 187 

gets is of air blown through a tube possessing some 
elasticity. In the blowing sounds heard in diseases of 
the respiratory apparatus, the listener gets an idea of 
obstruction ; the air does not pass as freely as in health. 
In one case the sense is of constriction — evidently the 
calibre of the tube has been diminished— the sound has 
the higher tone or shrillness that would be thus pro- 
duced. In another case the obstruction is evidently 
within the tube, either from fullness of mucous mem- 
brane, or from increased secretion, and the sounds are 
lower in tone — duller — or show the evidence of mucus in 
more or less of gurgling. In a third class of cases, the 
obstruction is evidently from want of elasticity and 
tone in the tube, which yields before the passage of air, 
both in inspiration and expiration — the wavering tone 
of the sound determines this condition. 

In so far then as we have analyzed the simple char- 
acter blowing, we have suggested to us a rational prac- 
tice of medicine. Contraction of bronchial tubes is in 
the majority of cases from irritation — employ those 
remedies which take away the irritation. Fullness of 
mucous membrane suggests the use of means to relieve 
determination of blood, and to promote absorption 
Increased secretion suggests the employment of means 
to take away irritation and determination of blood, and 
check secretion. "Whilst the wavering sound indicating^ 
atony, calls for stimulants, tonics and restoratives. 

Blowing sounds are dry and moist, and these common 
words express clearly the idea formed upon hearing the 
sounds. They are dry and moist, as they refer to a 
condition of dryness or moisture of the mucous lining 
of the bronchial tubes. 

Dry blowing sounds evidence a condition of bronchial 



188 STUDY OF DIAGNOSIS. 

tubes in which there is an impediment to the free 
passage of air, and more or less arrest of the normal 
mucous secretion. Dryness itself is an impediment to 
the passage of air, but in addition there is contraction 
of the bronchial tubes. We are in the habit of saying — 
as is the blowing, so is the contraction of the tubes — 
as is the sound of dryness, so is the arrest of secretion. 

Contraction of bronchial tubes results from irritation, 
and it suggests that such means be employed as will 
relieve irritation. Dryness results from irritation, de- 
termination of blood, and the developed inflammatory 
process. Given a dry blowing sound, we at once think 
of general and local sedatives which lessen determina- 
tion of blood, remedies which allay irritation, remedies 
which so rectify general lesions of circulation and tem- 
perature as to permit secretion, and remedies which 
restore secretion, if such be necessary. Thinking in 
straight lines, our ear gives us information of the con- 
dition of the air passages, we at once think of the 
pathological states, and having the factors of disease 
before us, we at once think of those remedies which 
restore normal functional activities. 

Moist bloicing sounds tell us of obstruction to the 
free passage of air. and to the pressure of fluid in the 
air passages. As is the blowing so is the impediment 
to the passage of air ; as is the moisture, rattling, bub- 
bling, gurgling, so is the amount of fluid in these pas- 
sages. 

The ear readil}"- determines from the character of the 
sound, whether the blowing is still due to contraction 
of the tubes, for in this case the sound is steadier and 
more resonant, than if caused by obstruction from accu- 
mulated fluids, or from atony. The well-sustained, 



STUDY OF DIAGNOSIS. 189 

sonorous sound always means contraction — contraction 
results from irritation — use remedies to lessen or take 
the irritation away. 

The impediment from secretion of mucus, muco-pus, 
or purulent fluid is clearly expressed in the sounds 
heard, and it is well to take the evidence of the ear, 
rather than an}' technical classification of sound. The 
presence of just sufficient secretion to lubricate the 
passages, of occasional accumulations which need re- 
moval by expectoration, of continued accumulation, 
giving rise to rattling sounds like the bursting of large 
bubbles, or the gurgling which comes from large quan- 
tities of fluid, are distinct and unmistakable. The 
treatment is clear — take away the causes of determina- 
tion of blood, whether due to irritation of the respira- 
tory nerves, or some general lesion. G-ive these tissues 
such support as we can, by the use of remedies that 
give local or general stimulus and tone. And to a cer- 
tain extent favor the removal of these accumulations 
by expectoration — usually by giving strength to the 
respiratory apparatus. 

The evidence of atony of the respiratory passages 
is found in the yielding or tremulous character of the 
sound. Whilst the evidence of contraction was found 
in the loell sustained sound, this is found in the feebly 
sustained sound. The treatment is clear — to sustain 
and increase the strength of the patient, and to stimu- 
late and strengthen this enfeebled organism. In some 
cases alcoholic stimulants give prompt relief, and their 
effect is maintained by Quinine, restoratives, and food. 
The local remedy is Lobelia in stimulant doses, and we 
always think of this, especially in infancy and child- 
hood. 



190 STUDY OF DIAGNOSIS. 

When cavities are formed in the lung, communicating 
with a bronchial tube, the ear detects a peculiar blow- 
ing sound, as of air blown into a bottle. This may be 
dull and more or less gurgling, showing that the pro- 
cess of removal is not yet completed, and the walls of 
the cavity are of the spongy, partly broken down lung. 
Or it may be clear, well sustained, and more or less re- 
sonant, showing the removal of deposit, and cicatriza- 
tion. 

Small bloving sounds, varying in character, shrill, 
whistling, piping, irregular, tortuous, dry, moist, rat- 
tling, all combined, in varying proportions, are the best 
evidences of phthisis pulmonalis. If the reader will 
think for a moment of the structures involved, the 
situation of the tubercular deposits, how they must 
press upon the smaller bronchial tubes, changing their 
position, making them tortuous, changing their.calibre, 
he will see at once that these are just such sounds as 
might be expected. 

In addition to these small, queer, blowing sounds, the 
ear detects that known as dry crackling. During a full 
inspiration three or four distinct crackling sounds are 
heard, which seem to the ear very much like the sounds 
produced by separating two surfaces attached \>y a glu- 
tinous fluid. And undoubtedly this is the condition, 
for if the tubercle is so deposited as by pressure again&t 
a bronchial tube to efface its cavity, the separation of 
the glutinous walls of mucous membrane would give 
just such sound. 

Crepitant sounds take the place of the respiratory 
murmur, and are formed in the air-cells, the intercel- 
lular passages, and the minute bronchial tubes. When, 
therefore, small crepitation is heard, we refer it at once 



SttJDY OF DIAGNOSIS. 1 91 

to disease of the parenchyma of the lung. If we in- 
quire into the condition of the lung — the changes of 
structure that will produce such sound — we find it in 
irritation, determination of blood, and slight effusion 
into these minute air passages. If the effusion goes on, 
the lung is rendered impermeable to air, and the crepi- 
tant sound ceases. 

Crepitance is therefore the evidence of inflammation 
of the lung in its first stage, and is associated with re- 
sonance on percussion, for the disease has not pro- 
gressed to hepatization. Where effusion has taken 
place to the extent of giving dullness on percussion, 
the crepitant sounds are replaced by blowing sounds 
from the bronchial tubes, the lung being now a better 
conductor of sound. Larger crepitance refers us to 
the minute bronchial tubes, and is the evidence of 
capillary bronchitis. The smaller crepitance is not 
only heard in the first stage of an inflammation of the 
'ungs, but returns with the absorption of the effused 
material, and resolution, and is therefore the evidence 
of the subsidence of the disease. 

As crepitance is the evidence of the active stage of 
an inflammation, in which irritation and determination 
of blood are the prominent factors, the treatment is 
plain. In so far as we can take away the irritation, 
and stop the determination of blood, our treatment 
will be rational. The frequent pulse, the high temper- 
ature, and the rapid respiration, are important elements 
in the furtherance of the local disease, and means 
whieh will rectify these wrongs, are of first importance. 
As the succeeding stage is one of local depression of 
life, no means should be employed that will depress 
either the life in general, or of the affected part. 



192 STUDY OF DIAGNOSIS. 

Where solidification of a lung has taken place, it 
becomes a better conductor of sound, and if now the 
ear is applied and the patient is engaged in conversa- 
tion, the voice seems to come out through the chest. 
We do not get articulate speech, but simply the modu- 
lations of the voice. This is called bronchophony 
(speaking through the bronchial tubes), but its only 
value is to determine solidification of the lung, and per- 
cussion is the better evidence. 

If there is fluid in the chest, and the ear is applied 
over it, the patient conversing, the voice seems to come 
out through the chest, but has a tremulous tone. This 
has been called segophony, and is one of the evidences 
of fluid in the pleural cavities. 

If the ear is applied over a cavity, which is free and 
communicates with a bronchial tube, and the patient is 
engaged in conversation, the articulate voice comes to 
our ear through the chest. This is called pectoriloquy, 
and is additional evidence of the formation of a cavity 
in the lungs. 

In some cases of structural disease of the pleura, the 
result of inflammation, certain Friction sounds are 
heard, but they are not very common, distinct, or defi- 
nite. Once in a while they are said to assume the dis- 
tinctness of the : - creaking of new leather," but in the 
two cases I have seen, the sounds were evidently 
from wrong of the parenchyma of the lung, and not 
from the change of the pleura. 

We employ auscultation in the examination of the 
heart with as much advantage as in diseases of the 
respiratory apparatus. As the sounds produced by the 
heart are much louder, and more distinct or arbitrary, 
many persons will succeed better in auscultation of the 
heart, than of the lungs. 



STUDY OP DIAGNOSIS. 193 

The normal sounds of the heart are smooth, uniform 
in tone, regular in time, and give the ear an agreeable 
sensation. No description in words would give the 
reader a sufficient knowledge of them; they must be 
heard to be thoroughly known. It is hardly worth 
while to call the reader's attention again to the impor- 
tance of knowing the phenomena of life for himself, 
and especially with regard to things that may so easily 
be known b}~ the senses. 

If, in examination of the heart, we find that the 
sounds are normal, we are quite sure that there is not 
structural disease of this organ. If there are general 
symptoms of heart disease, the wrong is functional. 
If, on the contrary, the sounds of the heart are changed. 
or replaced by adventitious sounds, we are just as sure 
that there is structural disease of the organ. The two 
exceptions to these rules are : — 1st, in case of anaemia 
or spansemia, we hear blowing sounds, which are re- 
ferred to the wrong of the blood, and not to the heart; 
and 2d, in fatty degeneration, no change in the sounds 
of the heart announce the structural lesion. 

The morbid sounds of the heart may be divided into 
blowing and sawing, and the ideas convej 7 ed D3 7 these 
words represent exactly the character of the sound. 
Whilst blowing sounds may be referred sometimes to 
lesions of the walls of the heart, and a wrong in mus- 
cular contraction, the sawing sounds are referred to 
the openings of the heart, and to the valves, and 
usually to lesions that obstruct the free flow of blood. 

The blowing sounds have been named bellows mur- 
murs, and have every range between the simple, 
smooth, blowing sound, similar to that heard from the 
bronchial tubes, to the roughened, irregular, rattling 
17 



194 STUDY OF DIAGNOSIS. 

sound, similar to that produced by a pair of bellows in 
motion. If the sound is dependent upon poor blood, it 
may man}' times be heard over the larger arteries as 
well as the heart, and in this case will call for the 
proper restoratives and food to make good blood. If 
dependent upon enfeebled nutrition, or degeneration 
of the walls of the heart, we employ means to give the 
heart rest, see that it is not subject to excitement, and 
employ means to improve nutrition. The rough, 
irregular sound that is attributed to valvular insuffi- 
ciency and regurgitation, would demand the same 
treatment. 

The saw sound has been divided into three varieties, 
the saw. rasp and file sounds, but the distinction has 
but little reference to conditions of disease, or to the 
use of remedies. Possibly the finer sounds may refer 
us to a more acute condition of disease, in which plastic 
material is yet being deposited. In some cases of val- 
vular insufficiency we hear a marked saw sound, but it 
has an irregularity and dullness that we do not meet 
with in the other cases. 

The more common lesions that give rise to contrac- 
tion of the openings of the heart, and such disease of 
the valves as prevent their free movement, are inflam- 
matory, and give fibrinous exudation as the result. 
The most of these are rheumatic in character, involving 
the tendinous portions of the muscle, and the endo- 
cardium. There are rare cases in which the sounds are 
due to fibrinous vegetations from the valves, or to 
ossific deposit in their structure. 

The treatment suggested by these sounds has refer- 
ence, first to rest, and secondly, to means which will 
promote absorption, and give us a better renewal of 



STUDY OF DIAGNOSIS. 195 

life. Rest is absolutely essential to recovery from 
chronic inflammation and the absorption of its pro- 
ducts. We want physical rest, and mental rest, and 
such relief from irritation of the cardiac nerves as may 
be obtained from the use of Cactus, Pulsatilla, and the 
special sedatives. Eemoval of deposits is facilitated by 
the establishment of free secretion, and a better heart 
is made by means to obtain good blood, and good 
nutrition. 

To determine pregnancy after the fifth month the 
ear is applied over the lower abdomen to hear the beat- 
ings of the foetal heart. If it is heard the diagnosis ie 
clear, but if not, we are not yet certain that pregnancy 
does not exist, for in many cases, from feebleness of the 
movement of the foetal heart, excess of liquor amnii. 
thick abdominal Avails, or the position of the child, it 
can not be heard until late in pregnancy, or not at all. 



DIAGNOSIS BY THE SENSE OF SMELL. 

The sense of smell has less development in the 
majority of men than any other of the senses — as some 
writer has recently remarked — " it is yet in the savage 
state." It may not be of much use in diagnosis, and yet 
the little it may tell us we want to know. It requires 
education, as do the others, and we must learn to dis- 
tinguish pleasant odors from stin7cs, and thus be able to 
analyze stinks, and determine their influence upon the 
human body. It is possible that some persons will 
never be able to recognize the genus " stink," much 
less be able to assort them for our present purpose. 

It is well for the physician to commence educating 



196 STUDY OF DIAGNOSIS. 

his nose at home, and to start with a realization of the 
fact that all unpleasant smells are noxious to the human 
body. It requires very little exercise of reason to 
reach this conclusion, for if the thing was not unplea- 
sant or noxious to the economy, the nose would not 
give the warning of unpleasantness. What is the evi- 
dence of disease to the person suffering? Unpleasantness ; 
the very expression used, " persons suffering," tells the 
story of disease. Is disease ever pleasant? No. Are 
causes of disease ever pleasant ? No. Do causes of 
disease ever pleasantly impress the senses? You 
might answer yes. but I say no again. 

Commencing at home I put my nose inside your 
office door, and — heaven preserve me — what a com- 
pound of stinks, from Asafoetida to Jalap, from Castor 
Oil to Turpentine. Lesson No. 1, true remedies have 
no bad odor, clean up your stinks and put them in the 
nearest privy-vault, and have a thorough disinfection. 
Reason why — it will be money in your purse— people 
that pay good bills don't like stinks, as a rule. Let me 
nose your saddle-bags and pocket-case ? Faugh ! what 
a terrible sickly smell! — reminds me of the old country 
doctor, who was always announced by a mixed smell 
of Asafoetida and Jalap. It won't do in this age ; burn 
them up, and order a new stock. Now clean up your- 
self, and get your nose in good working order, that you 
may learn diagnosis with it. Do you know how to eat 
onions and go-a-sparking too ? Have the maiden taste 
them. Reverse the simile — if you cany bad smells 
about you. you will not be able to detect them in the 
sick room — and it is a most important work, believe me. 

When I visit a sick room, my nose commences the 
inquiry, (it is a most excellent interrogation point), 



STUDY OF DIAGNOSIS. 1T( 

What provisions have you made for fresh air, sunlight, 
and cleanliness? It says straightway, the air is bad, 
there must be ventilation, and opens a window, builds 
an open fire, and does what is necessary. It noses a 
stink from under the bed. and suggests half cleaned 
chamber utensils, excreta, dirty clothes, dirtied floors, 
etc. It says with emphasis there must be a tuorougo 
cleaning up. The excretions muot be removed as soo~ 
as voided, the utensils thoroughly cleansed and dish) 
fected, every loose thing removed, the floor cleansed 
the bed drawn from the wall, and so arranged that th< 
air can pass freely under it. It says you have been 
trying to feed this patient upon stale, badly prepared 
food, and it detects it remaining in the room hour after 
hour, poisoning the atmosphere, and taking away what 
little desire the patient may have for nourishment. It 
says, the food for the sick must be nicely prepared, 
fresh and savory, at such times as he can best take it, 
and then promptly removed from sight or sense. It 
says — you are dirty — dirty in person, dirty in clothing, 
dirty in bed. You must be thoroughly cleaned up, 
washed with soap and water, have frequent changes of 
clothing and bed linen — " cleanliness is next to godli- 
ness." 

You can't hide dirty sheets from this nose, or a bed 
soiled by involuntary discharges, or a bed sore, a badly 
dressed wound, however you may try to cover them 
up. It recognizes the row of nasty medicine bottles, 
and says, "take them out" — your spoiled poultices 
and fomentations, and says, " fresh water." It tells 
you of damp walls, of lack of sunshine, of choked 
drains, of ground saturated with garbage, of foul 
closets, of cellars uncleaned, of decomposing vegetables, 



mm 



198 STUDY OF DIAGNOSIS. 

and of the hundred and one noxious agencies which 
breed disease and steal away a man's life. 

But it not only tells you of dirt, and specifies clean- 
liness as the remedy, but it tells of specific agents to 
destro} T causes of disease. I will warrant that you 
have already associated an unpleasant odor of decay 
with lime. Lime to freshen the air of cellar, lime to 
slush a bad drain or cess-pool, lime to make way for 
sunlight, and to get rid of the de-ad air of a house. 
You will recognize a sweetish, mawkish, unpleasant 
odor, similar to that exhaled from smallpox, and it 
says Sulphurous Acid, as plainly as it can be expressed. 
You burn Sulphur in the room, or in the whole house, 
and 3 t ou are surprised how it changes the air, and how 
much the patient is benefited by it. In other like cases 
you sprinkle the floors with Sulphurous Acid, wash the 
chamber utensils with it, and the dressings in surgical 
disease. It is not simply to get rid of a bad smell that 
we do this, but it is to remove a cause of disease. 

There are other cases in which a peculiar putres- 
cence reminds you that Chlorine, Carbolic Acid, or 
Iodine are required. You employ Labaraque's disin- 
fecting solution, or Chloride of Lime, and you see a 
decided improvement. Or you use a solution of Car- 
bolic Acid, especially as a wash to things which are 
soiled, to wash dressings, or as an application to 
wounds, and there is a change for the better. There 
is a bad odor that simulates the offensive sputa of 
chronic bronchitis, and some cases of phthisis, which 
would at once suggest Iodine, and we use it as a disin- 
fectant, a dressing, a local application, or as an'inha- 
lation. So too there is an unpleasant odor, peculiar to 
phlegmonous erysipelas, that says Permanganate of 



STUDY OF DIAGNOSIS. 199 

Potash so plainly that no one can mistake the remedy. 
I do not wish to jDlace too much stress upon the evi- 
dence of this sense, for as stated in the beginning it is 
but rudimentary, yet some things it does tell us with 
certainty. A sweetish or mawkish odor from the 
breath wants Sulphurous Acid, or Sulphite of Soda. 
An odor resembling an offensive lochial discharge, is 
the best evidence of the want of Chlorate of Potash. 
The hot breath, with unpleasant pungence, as ot Am- 
monia, calls for Muriatic Acid. The fetor resembling 
that from cynanche maligna, calls for Baptisia. 

But whether we can distinguish one bad smell from 
another or not, we know one thing, that they demand 
cleanliness, good ventilation, and a restorative treat- 
ment Going one step further, they evidence the con- 
dition of sepsis or zymosis, and demand that we select 
the proper antiseptic. If we can select it from the 
odor, good ; it not, and in any case, we have other ex- 
pressions of disease that will point out the particular 
remedy required. 

If we apply the sense of smell to the excreta we find 
it of some value, though possibly not of very much. 
The cutaneous excretion gives a distinctive odor, and 
in disease we sometimes find marked changes in this. 
It is not difficult to recognize the pleasant odor from 
the healthy skin, kept clean, as it is not to recognize 
the odor of the p.erson kept dirty. In treating children 
the evidence of our nose is frequently opposed to the 
evidence of our eyes. The child seems clean, but the 
unpleasant odors tell you to look beneath the surface, 
and it is dirty. We find all manner of odors from the 
person, running the range of " from grave to gay," and 
they tell the story of disease and vitiated secretion. 



■^■™« 



200 STUDY OF DIAGNOSIS. 

Some of these are so characteristic that they can not 
be mistaken, as for instance, the peculiar urinous smell 
in tinea capitis. 

The urine has a distinctive odor, that may be called 
healthy. It may lose odor, or it may have a wide range 
of morbid smells, each of which should have a distinct 
meaning in the diagnosis of disease. If a Septimius 
Pease were to study uriscopy, he would probably trust 
his nose in preference to his eyes. 

The seminal odor is so distinctive that it can hardly 
be mistaken, and as it is very persistent, and may per- 
vade the entire person, it will sometimes give impor- 
tant information. So too is the odor from the sexual 
organs of both male and female, in certain cases of 
disease. 

The fetor of the faeces is peculiarly unpleasant, yet 
the odors are distinctive, and would suggest health in 
one case, and disease in another. I have no penchant 
for the olden-time examination of faeces, yet even here 
I would about as soon trust my nose as my eyes. Pos- 
sibly the characteristic stinks, already named, will be 
found here, and the same class of remedies indicated. 



INFORMATION FROM PATIENT AND NURSE. 

We neglect no source of information with reference 
to the origin, condition, or progress of disease, and 
whilst careful not to be guided by information from 
nurse, friends and patient, we wish to give it its true 
value. Attention has already been called to the many 
sources of error. To a want of knowledge and care 
in observation on the part of nurse and friends, as wel* 



STUDY OF DTAQNOSrS. 201 

as their prejudices and tendency to distortion. To the 
want of knowledge upon the part, of the patient, want 
of language for description, and the impairment of his 
powers of sensation and reason from disease. 

The elements of uncertainty are thus very great, and 
we have to pursue our inquiries with much care. 
Questions should never be suggestive, but should be so 
put as to let nurse or patient tell what the} T know, or 
to require but the simple and direct answer, yes or no. 
Careful attention to these points, and a continued guard 
upon the tongue, will soon form a habit of examination, 
that will lessen the danger of erroneous information. 

We prefer to get information from attendants with 
regard to the general condition of the sick, and the 
performance of the essential functions of life. From 
the patient we desire to know his sensations, as these 
are changed by disease. 

A first examination may take the following course : 
How long sick? What are the seeming causes of the 
sickness? How did it commence? What has been 
noticed Avith reference to the progress of disease up to 
the present time? How does the patient rest in the 
daytime ? at night ? What food and drink does he take ? 
How often does he have a motion of the bowels? How 
does he pass urine? These questions may seem sug- 
gestive, and once in a while they may take a simpler 
form as — does he sleep? does he eat? does he drink? 

It is most absurd for the attendant to attempt a de- 
scription of the sensations of the sick, and yet they 
almost always volunteer to do it. Many times they 
will be continuously making suggestions to the patient, 
and lead him into erroneous statements. They will 
probably have formed some theory of the disease, and 



202 STUDY OF DIAGNOSIS. 

will bend everything to the support of their theory. 
Physicians are very frequently guilty of this, and 
should try to get rid of the bad habit which they con- 
demn in nurses. 

The question — how do you feel ? elicits a loose, wan- 
dering description of the patient's sensations, and is 
only important, in that it suggests special questions and 
examinations. The question — where do you feel bad? 
is pertinent, and will elicit valuable information of 
local disease. It does not do to take it for granted 
that the patient's anatomical or physiological knowl- 
edge is perfect, and that his reference to heart, lungs, 
stomach, liver, etc., means heart, lungs, stomach, liver. 
The direction at once follows — put your hand on the 
place. It is a little singular to find after a patient has 
located a disease in his own mind, the hand meanders 
about with uncertainty, trying to find its location. If 
the unpleasantness is marked, and means local disease, 
the patient has no difficulty in placing his hand upon 
the exact spot. 

If there is anything uncertain in the patient's man- 
ner or method, and especially if uneducated, we wish 
him to describe his sensations, with the hand upon the 
affected part In many cases we will find that the de- 
scription commences to wander as soon as the hand is 
removed. There is a reason for this ; with the hand 
upon the part, the mind is directed to it and concen- 
trated, extraneous ideas are rejected, and the descrip- 
tion is of actual sensations. 

We want to know the character of the pain, its dura- 
tion, exacerbations and remissions, periods of recur- 
rence, and its influence on function. In this examina- 
tion the physician 'should show by his questions and 
manner that he wants concise and specific answers. 



STUDY OF DIAGNOSIS. 203 

The subject of pain is a study of itself, and much 
less is known of it than we would wish. In some 
cases it indicates the special remedy which will cure, 
in others it simply points to a pathological condition, 
and remedies must be selected by other symptoms. 

Thus if we have a pain in the head, heavy, tense, 
and sleepy, we give Belladonna ; if it is sharp and 
restless, G-elseminura ; if sharp, limited in location, de- 
spondent, Pulsatilla. If of the frontal region and 
orbits, with burning. Ehns ; if of the right side passing 
from before backwards, Biyonia ; if of the back of the 
head, dull and heavy, Iron. 

The pain in right hypochondrium, pointing to the 
umbilicus, indeed, all pains pointing at the umbilicus, 
Nux Vomica. Pains deep in the ischiatic notches, 
Podophyllin. Pains that are tensive and paroxysmal, 
Macrotys. 

The pain of Macrot}'s is a singular one. It feels as 
if dependent upon tension, and is decidedly remittent — 
a continued succession of tensive pains. We usually 
prescribe Macrotys for muscular pain, no matter what 
its character, and hit it in a large majority of cases. 
For this remittent tensive pain — waves of pain — no 
matter where it is, we may prescribe the Macrotys with 
certainty, (the pain is not throbbing.) A recent case 
of facial neuralgia was very striking. The gentleman 
had suffered for some weeks, and had taken various 
remedies without relief; and I had made three failures 
uvyself. Close questioning brought out the character 
of the pain, and Macrotys gave prompt relief. 

I admit that it is very much easier to prescribe from 
the location of the pain, than from its character, for 
whilst a patient may be able to locate it correctly, it is 
not possible for him to describe its character. 



204 STUDY OF DIAGNOSIS. 

If we take the pain of Lobelia, we will find its prin- 
cipal characteristic anguish, of which angina pectoris 
and neuralgia of the heart offer the most common ex- 
amples. It is that indescribable sensation as if the life 
was being forcibly riven from the part — anguish ex- 
presses it. Lobelia is specific to it. Give twenty to 
forty drops of a good tincture of the seed to a person 
suffering from angina, and there is instant relief, which 
becomes complete in a short time. I have seen one 
case of uterine neuralgia presenting this character, and 
from which the patient had suffered beyond conception 
— a single dose arrested the paroxysm ; and its repeti- 
tion when the symptoms were felt, gave a radical cure. 
I have seen two cases of abdominal pain presenting this 
character to some extent, and both were relieved by 
Lobelia. A singular case of hypochondria, in which 
the feeling as if a movement of the body would endan- 
ger life, but without pain, was cured with Lobelia, 

The peculiarity of this pain or sensation is so dis- 
tinct, that patients may describe it. For many years 
(indeed it was one of the first things I learned in prac- 
tice) I have given Lobelia in certain cases of labor 
where the pains assumed this character. Every one 
will have recognized the two classes of pain, one of 
which is well borne, which is really relieved by the 
action of the will, and the other which finds no such 
antagonism. In the latter class I find the indication 
for Lobelia, and it has proven one of the most efficient 
agents I have ever used in obstetric practice. Of the 
two agents Ergot and Lobelia, I would take the last a 
hundred to one. 

Let me briefly call attention to the abdominal pain 
of Nux Vomica. 



STUDY OF DIAGNOSIS. 205 

I say it ib any pain having a tendency to point at the 
umbilicus; it is pretty accurately located. It may be a 
simple colic, a bilious colic, a derangement of the func- 
tion of the liver, a wrong of the spleen, a dj'smenor- 
rhcea, a disease of the colon, irritation of the bladder — 
if the pain shows the constant tendency to the umbili- 
cus — I should give Nux. I should fail sometimes, but 
the failures would be small in proportion to the suc- 
cesses. The definiteness of the symptom, and its easy 
recognition, are what please me. 

The pain indicating Khus Toxicodendron is very dis- 
tinctive. Frontal pain, especially involving the orbits, 
and inclined to be more severe on the left side. Such 
pain would lead me to prescribe Eh us, if there were no 
other indications. Add the peculiar appearance of the 
papillae at the end of the tongue, and I would have a 
positive assurance of success. ■ To any pain add burning 
and we would think of Ehus as a possible remedy. 
Given, the pains of rheumatism with burning, and Ehus 
is the anti-rheumatic, or is alternated with Macrotys. 
A case of puerperal fever this Summer in which burning 
sensations and pains were pronounced, was cured with 
Aconite and Ehus; and arrested so promptly that there 
could be no mistake in the action of the remedy. 

The pain calling for Bryonia, whilst it may be sharp 
or dull, alwa}~s has with it a sense of oppression, as if 
the part were enfeebled, and could not perform its 
function. Homoeopaths speak of burning as character- 
istic of this pain, but I have not been able to see it. 
Take a case of pleurisy, or pleuro-pneumonia, or pneu- 
monia, with this sense of oppression and feebleness, as 
if the part could not and should not do its work, and 
Bryonia, with the proper sedatives, will prove curative. 



206 STUDY OF DIAGNOSIS. 

In the same way a rheumatism giving the same symp- 
toms of inability, with increased pain following the 
use, will be cured with Bryonia. 

The pain calling for Belladonna is dull, heavy, full, 
with a sense of functional impairment. It makes but 
little difference where you find it, or in what disease ; 
whether a simple headache, an ague. - : bilious fever," 
or inflammation of the lungs, Belladonna will prove 
curative. 

The pain calling for Stramonium is constrictive, and 
when involving muscular structures, is attended with 
persistent contraction, and of the outlets of the body 
is expulsive. A case of dj^sentery. with most violent 
expulsive movement of the pelvic muscles, was speedily 
relieved with Stramonium; as was a case of broncho- 
pneumonia, showing as a symptom a most marked and 
unnatural constriction of the chest. 

The pain calling for GJ-elseminum has as a marked 
feature exalted sensibility and arterial throbbing. In 
some cases, especially in the head, the patient dreads 
movement, and the puliation of the arteries is distinct 
and painful. With such pain in any part of the body, 
we would prescribe G-elseminum with every assurance 
of success. 

The pain calling for Chelidonium is dull, heavy, ten- 
sive, with occasional twinges, as if the part was being 
torn. Situated in the hypochondria or epigastrium, 
Chelidonium is the :; liver " medicine. 

The pain calling for Iodide of Ammonium seems to 
involve a definite amount of tissue, as in inflammation, 
and yet points at some particular place w^hich might 
be covered w r ith the tip of the finger. 

In thus calling attention to the symptomatology of 



STUDY OF DIAGNOSIS 207 

pain in therapeutics, I do not wish to be understood a< 
claiming that it is infallible. Our own senses are sui 
ficiently imperfect, even when trained by long obser 
vation. The senses of the patient are untrained ano 
impaired by disease, and his descriptive powei*p m&^ 
be very feeble. 



NOSOLOGY. 

A distinct department which has for its object the 
classification of diseases, is named nosology, and though 
we do not propose to make such classification, the sub- 
ject demands a brief study. In so far as the ordinary 
classification facilitates study, and the knowledge of 
disease,' it will prove beneficial, but whenever it ia 
made the basis of therapeutics, it must work an injury. 

Nosology is said to have three objects of considera- 
tion : 1st. The distinction and definition of particular 
diseases. 2d. The nomenclature of the diseases, or the 
assignment of the names b}^ which they are to be des- 
ignated, so that each disease may be distinguished and 
known b}' an appropriate name. 3d. The arrangement 
or classification of diseases in some methodical and con- 
venient order by which they may be distributed into 
classes, orders, genera, or species." 

We employ this method in natural history, and 
divide animals and vegetables into " classes, orders, 
genera, or species ;" why should we not employ it in 
the study of disease ? If one will think for a moment 
the reason will be obvious. The individual, animal, or 
vegetable, is a distinct, tangible entity ; disease is a 
method of life. When we use this classification, we 



208 STUDY OF DIAGNOSIS. 

think of the object as things, not conditions or states. 
Thus this method of classif} T ing disease carries to the 
mind the idea of disease as an entity, a thing that has 
precise form and condition. This idea has been the 
foundation of an erroneous practice, and the obstacle 
to a successful study of medicine. 

The reader will understand me to say that so far as 
therapeutics, or the giving of remedies for disease is 
concerned, the common nosology is a continued source 
of error, though in so far as it may facilitate the study 
of pathology it may answer a good purpose. Used to 
direct the means of cure, it is wholly insufficient, and 
many times erroneous. Under single names are 
grouped the most diverse characters of disease, varjnng 
in different persons and at different times. 

If disease is an entity, the doctor thinks of his medi- 
cine as a policeman who takes that entity by the 
collar and walks it out of the body. Why not? 
"Worms" is a disease, then ascaris lumbricoides, a 
variety of this disease — send in Mucuna Pruriens to 
tickle the disease to death and make it u vamose the 
ranche." Or, we might arrange it as follows : Class — 
eccritica ; genus — malls; species — pediculis capitis ; treat- 
ment — crack them. 

It does look a little funny when we take this view of 
it, and yet you may say that this is an exceptional 
case ; let us see. Disease erysipelas, grows by continuity 
of structure ; treatment — fence it n and keep it from 
spreading And so the doctor takes Nitrate of Silver, 
Tincture of Iodine, or Tincture of Muriate of Iron, 
and makes his dark line on the outside of the disease, 
saying, here is an obstruction, I want you to stay on 
your own side. If the erysipelas had been a vicious 



STUDY OF DIAGNOSIS. 209 

animal, be could not have built bis fence with a more 
determined purpose. 

If the reader will think for a moment, be will be 
surprised how strong a hold this idea of disease as an 
entity has upon the profession, and how it is made to 
serve as a basis for the most unpleasant medication. 
The physician forgets the life of the patient in his effort 
to rid him of his disease — a disease that he has caugbt, 
or one that has caught him. He forgets the impair- 
ment of life, the functional wrongs; that disease is a 
condition of life — is life, and that it can not be vomited 
through the mouth, purged from the bowels, sweated 
from the skin, passed with the urine, drawn by a lancet 
from the bloodvessels, killed with mercury or tartar 
emetic, or so afflicted by the class antiphlogistic that in 
sheer desperation, it will take itself out of the body. 

Distinction and Definition. — Our authorit}^ says 
that the first object of nosology is "the distinction and 
definition of particular diseases, or of their genera and 
species." Here is the common error, of disease as an 
entity, for which he wishes a distinction and definition. 
He does not desire a definition of pathological life or 
groups of unvarying pathological wrongs, but such dis- 
tinction as will enable him to affix a name. 

Neither are we to understand that this " distinction 
and definition " is to have reference to means of cure, 
or indeed that they will serve as any iruide to reme- 
dies. Aitken remarks : " In modern times the great 
advantages that have arisen from establishing defini- 
tions in natural history upon fixed and determinate 
principle, not only of its various objects individually, 
but also of the groups under which it was found pos- 
18 



210 STUDY OF DIAGNOSIS. 

sible to arrange them, suggested to medical men the 
idea that much advantage might also result to the 
science of medicine from denning diseases, and such 
groups of diseases as might be found expedient to re- 
cognize, under general terms or common names, based 
upon some fixed and determinate principles." The 
reader will notice in this quotation the tendency to the 
error named, and the student finds it impossible to 
read medicine without getting the idea, that diseases 
thus classified must be something definite, like the 
animals and vegetables whose classification is appro- 
priated. 

Nomenclature. — The second object of nosology is 
to name the diseases thus defined, and the medical 
world has travailed in labor with names, for many 
years. It is very much as recorded in Genesis : " And 
out of the ground the Lord G-od formed every beast of 
the field, and every fowl of the air, and brought them 
unto Adam, to see what he would call them ; and what- 
soever Adam called every living creature, that was the 
name thereof." 

A name should carry to the hearer an accurate idea 
of the person or thing in its various attributes, and if 
names of diseases did this we could not object. In so 
far as names do indicate the wrong of life, names are 
useful as guides to correct practice. In so far as 
names direct the mind in pathological inquiry, they 
will prove of advantage in medical study. But when- 
ever they are recognized as entities, at which remedies 
are to be hurled, and which must be forced out of the 
human body, then they will prove a source of error. 

Plancquet claimed that " the name of each disease 



STUDY OF DIAGNOSIS. 211 

or species should be so significant that a person slightly 
acquainted with the language and the subject, should, 
on hearing it, immediately understand what is the 
nature of the disease it designates." To such a nomen- 
clature we should not object, and if it should go one 
step further, that on hearing it we should immediately 
understand what remedy would rectify the wrong, or 
cure it, then it would be perfect. 

If we take the nomenclature of the Royal College 
of Ph3 7 sicians, of London, we find 1,146 distinct dis- 
eases, and if we would add the named sub-classes or 
varieties it would bring the number up to near 2,000. 
A man has one right life, and his varied physiological 
processes can be studied under one or two score heads, 
but his wrong life requires a classification under 1,146 
heads, or distinct varieties. 

If we examine the therapeutics which go with this 
classification, we find that it numbers but about one 
hundred remedies in use, and but about twenty in gen- 
eral use, and of these five to ten are in common use for 
everything. This shows a wonderful discrepancy 
between the nosology of disease and its therapeutics. 

Classification of Diseases. — Probably more is 
gained in the classification of disease than in its nomen- 
clature. The object of classification is to notice the 
resemblances rather than the differences, to determine 
the pathological wrongs common to a series of diseases, 
rather than to determine the special symptomatic dif- 
ferences. With regard to classification, Dr. Aitken 
remarks : 

" It is obvious that any single character, or combina- 
tion of characters, in respect of which diseases agree 



212 STUDY OF DIAGNOSIS. 

with or differ from each other, may be made the basis 
of methodical arrangement, under a larger or smaller 
number of divisions, or of higher or lower genera 
(language of logicians), or of classes, orders, and genera 
(language of naturalists). B3- ingenious devices of the 
mind the physician or the statist may classify and 
arrange his knowledge so as to bring it all more readily 
within his reach for any special purpose — so as to make 
it, in fact, more at his disposal — -to facilitate and pave 
the way for further investigation. Such are the legiti- 
mate objects and the results of all methodical arrange- 
ments. Classification, therefore, being only a method 
of generalization, there are, of course, several classifi- 
cations of disease which may be used with advantage 
for special purposes. The physician, the pathologist, 
the jurist, the hospital statist, the army or navy medi- 
cal officer, may each legitimately classify diseases from 
his own point of view, and for his own purposes, in the 
way that he thinks the best adapted to facilitate his 
inquiries, and to yield l.im general results. The 
medical practitioner may found his main divisions of 
diseases on their treatment, as medical or surgical; the 
pathologist, on the nature of the morbid action or pro- 
duct; the anatomist or the physiologist, on the tissues 
and organs involved ; the medical jurist on the sud- 
denness, slowness, violent or unnatural mode of the 
death ; the hospital statist, on the kind of diseases 
which are treated in its wards; and all of these points 
of view may give useful and interesting results, (Fare). 
" There is thus no question on which more diversi- 
fied opinions are legitimately entertained than on that 
of classification. Although it is the aim of all syste- 
matic writers and observers to arrange the objects of 



STUDY OP DIAGNOSIS. 213 

study in the most natural order possible, and although 
diseases are named as if they were individual entities, 
yet they present so great varieties that the}^ will not 
admit of that definite and, in many respects, natural 
species of classification which can be made with objects 
of natural history. Manifest reasons of convenience 
and facility for work. can therefore be assigned as the 
great incentive to classification; and numerous reasons 
exist for classifying diseases in various ways : (1.) Men 
differ in their estimation of the characters on which 
different arrangements may be founded. (2.) The 
facts and phenomena of diseases on which classifica- 
tions may be made are not all regarded from the same 
point of view. Most systems are avowedly artificial^ 
being arranged with the view to elucidate or support 
a theory, or otherwise to effect a definite end. For ex- 
ample, by classifying diseases and recording the causes 
of death, the most valuable information is obtained 
relative to the health of the people, or of the unwhole- 
someness and pestilential agencies which surround 
them. ' We can take this or that disease,' says Dr. 
Farr, ' and measure not only its destructiveness, but 
its favorite times of visitation ; we can identifj^ its 
haunts and classify its victims.' We are able to trace 
diseases also as thej^ perceptibly get weaker and weaker, 
or otherwise change their type, as some have done from 
time to time. We know from the valuable returns of 
the Eegistrar-General, prepared periodically by Dr. 
Farr, that certain diseases are decreasing, or growing 
less and less destructive ; that certain other diseases 
have ceased in some measure ; while other severe dis- 
eases have exhibited a tendency to increase. The ad- 
vantages, therefore, of adopting some system of class i- 



214 STUDY OF DIAGNOSIS. 

fying diseases, which can be put to such useful prac- 
tical purposes, must be obvious to every one." 

If one can free the mind from the idea that nosology 
has a direct relation to therapeutics, these subjects may 
be studied to advantage. AYe want to learn the natural 
history of diseased life as we have learned the natural 
history of healthy life. If a classification and nomen- 
clature will aid in this, even if only as guide boards 
and mile posts, we may employ them. 

To a certain extent, the common nomenclature of 
disease is a necessity. It is quite as necessary to be 
able to name a disease for the satisfaction of friends, 
as it is to give successful treatment The name may 
not probably have anything to do with the manage- 
ment of the case, or the selection of remedies, indeed 
should have nothing to do with it, yet we are forced to 
give a name. The first question asked of the physician 
in the sick room is. •' What do you call it ? " and we 
must be able to ' ; call it " correctly according to the 
commonly received nosology. 

If we can simplify our classification, so as to make it 
a good guide for study, we will do well ; if we can 
make it suggestive of causes of disease which may be 
avoided, of right attention to hygiene, and an outline 
of treatment, we will have accomplished all that can 
be reasonably anticipated. Let us see how far we can 
make such classification. 

The first division will have reference to causes of dis- < 
ease, as well as to pathological conditions. It will be 
into epidemic, contagious, endemic and sporadic diseases. 
The reader will notice that this is a natural classifica- 
tion, referring to causes of disease and their avoidance, 
and to a less extent to the conditions of disease and 
means of cure. 



STUDY OF DIAGNOSIS. 215 

The second division will have reference to the general 
or local nature of the morbid states, and as will be 
noticed occupies the same ground as the preceding, 
this having reference to the conditions of disease and 
not co its cause. All disease may be classified under 
these two heads, though many times it will only have 
reference to the primary lesion, for as the wrong goes 
on, a disease which was primarily general becomes 
localized, and one which was primarily local will cause 
general disease. 

A third division has reference to the structure of 
parts or to their functional expression, and diseases are 
divided into structural and functional. Again, it will be 
seen that this classification of disease occupies the 
ground of both the first and second, for all disease 
must be structural or functional. Here, as before, we 
find it especially applicable to the primary disease, for 
one may have commenced as a functional wrong, and 
grown into a structural disease, as a structural disease 
may have first existed, but this being cured, other func- 
tional lesions persist. 

A fourth division might be called physiological, and 
would have reference to the functions of the body. 
If, for instance, we make the usual classification in 
teaching the principles of medicine : 

{Formative, 
Heat, 
Electricity. 

{Formative, tissue making. 

Secreting, does the work of secretion. 

Necrological, pus cells. 

( Digestion, 
Nutrition J Blood making, 
(Tissue making. 



m 



216 



STUDY OF DIAGNOSIS. 



Secrotio 



ion. < 



Kecrementitious, 
Excrementitious. 



{Arterial, 
Venous, 
Capillary. 



Innervation 



f Brain, 

. 4 Spinal 

ISyrnpa 



cord, 
pathetic. 



Taking this classification, and assuming that there is 
a normal standard of health which may be known, and 
that disease is a departure from this standard, all 
lesions may bo classified as being in excess, defect, or 
perversion. This classification is used by Dr. C. J. B. 
Williams in his Principles of Medicine, as in the follow- 
ing tables: 

PRIMARY ELEMENTS OF DISEASE. 



STRUCTUBAL CONSTITUENT. 



ITS FUNCTION. 



STRUCTURAL DISBA.8B 



Contractile fiber. 



( Irritability. 
( Tonicity. 

("Tubular (the con- f 
duetor of nerve 1 Sensation. 

| force.) I Voluntary motion. 

Nervous <{ Vesicular (the { Involuntary motion, 
structure I generator and (excited motor ac- 

| combiner of nerve | tion.) 

(.force.) (.Sympathetic action. 

Secreting structure. Secretion. 
Red corpuscles. 
White corpuscles. 
Fibrin. 
Albumen. 
ary com-^Oil, and combus- 
ponents tive matters, 

of blood. Inorganic ingredients, 
I (saline and mineral ) 
C Water. 

'By respiration. 
By secretion. 
By nutrition. 
By foreign matter. 



Element- 



Elementary 
changes in 
the blood. 



Excessive— Hyper- 
trophy. 



Deficient — Atro 
phy. 



Perverted— Degen- 
eration. 



STUDY OF DIAGNOSIS. 217 



PROXIMATE ELEMENTS OF DISEASE. 



Deficient in quan- f General, 
tity— Ansemia. 1 Partial. 



f General— Plethora. 



+Tt| Increased— Sthenic. 
^s Dirain'd— Asthenic. 



a Increased — Determi- 
ne nation of blood. 

.-£ « Dimin'ed— Congest'n. 

►£3 Partly inc. Mnflam- 

2 Partly dim. fmation 



Excessive in | 
quantity — Hyper- -{ 
aemia. 

I Partial — Local hy 
L Perv'ted in qual- I. persemia. 

gn ' ity — Cachsemia. 

fDeficient — Atrophy. o 

Nutrition of I Excessive — Hypertrophy, 
textures. < C Degenerations of tissue. 

J Perverted. < Morbid deposits. 
(. (^Morbid growths. 



If now we add to this the ordinary nomenclature of 
disease, employed in this country, the reader will have 
before him a brief resume of nosology. It will be seen 
that these various classifications point the way to certain 
necessary studies, having reference to causes ^of disease, 
their general expression, their influence on the func- 
tions of life, and lastly the technical language by which 
they are designated and known. 

It will be recollected that diseases are first divisible 
into general and local, and the first may be arranged 
according to the classification of Wunderlich as follows : 

Tabes. 
Chlorosis. 
Scorbutis. 
Dropsy. 
General Disease — Dyscrasia.-{ Diabetes. 

Kheumatism. 
Pysemia. 
Tuberculosis. 
Carcinoma. 

Lesions induced by j ^f^onts. 

J { vegetable Substance*. 

19 



wm 



218 



STtJDY OF DIAGNOSIS. 



f Intermittent. 
Rpmittent. 
Yellow, 
f Febricula. 
J Synocha. 
Fevers, ^j Continued. \ Svnochus. 
| Tvphoid. 
t Typhus. 

Eruptive, (J*™ 1 *' 
n 'S : i Scarlatina. 
Contagious, j -r, -. -, 
fo I Rubeola. 

r Spotted. 

-7 +i« ] Cerebro-Spinal Meningitis. 
z,ymotic.-j p iphtheria 

[Erysipelas. 

Local diseases are usually arranged in groups accord- 
ing to the function of parts. This seems to be the 
most natural arrangement, as the expression of disease 
is frequently a wrong of function. 



Of the Nervous Svstem. 



Of the Brain. 1 a , , 

c, . , r, -, f Structural. 
Spinal Cord, v -,-, .. , 
^ ,, .. i Functional. 
Sympathetic.) 



f Eye — sight. 
I Ear — hearing. 
Of the Organs of Special Sense. -| Nose— smelling. 

| Mouth — taste. 
[Skin — touch. 



bg03 

§3 



Of the Respiratory Apparatus 



Of the Circulatory Apparatus. 



' Nose. 




Pharynx. 


^cc 


Larynx. 


§5 


1 Trachea. 


o O 


Bronchia. 


o = 


Lungs. 


SO z. 


Pleura. 




' Heart. 




Pericardium. 


hEjQC 


Arteries. 


3 C 


- Capillaries. 




Veins. 


5 'S 

3 r? 


Lymphatic Vessels. 


Sir* 


. Lymphatic Glands. 


• 



STUDY OF DIAGNOSIS. 



219 



f Mouth. 
Salivary Glands. 
Tonsils. 
Pharynx. 
I (Esophagus. 
. . _. M . . Stomach. 

Of the Digestive Apparatus, j Sma]] Int estine. 

Large Intestine. 
! Liver. 

Spleen. 

Pancreas. 
[Peritoneum, 
f Supra-renal Capsules 
| Kidneys. 
Of the Urinary Apparatus. \ Ureters. 
I Bladder. 
I Urethra. 



^ 03 



O P 






Of the Keproductive Organs. - 



{ Scrotum. 
Testes. 

Vesiculae Seminales. 
Prostate. 
Penis. 
Ovaries. 
Uterus. 
Vagina. 
Vulva. 
[Urethra. 
Cutis Vera. 
Rete Mucosum. 
Epidermis. 
f the Skin.-! Sudoriferous Glands. 
Sebaceous Follicles. 
Hair. 
^ Nails. 

f Bones. 
Articulations. 

Of the Organs of Locomotion.-! ,., \° ™. 

& 1 Muscular Tissue. 



Fibrous Tissue. 



5 % 

a o 






§ 5 

SB £. 



[Connective Tissue. 

The reader will notice that whilst this classification 
is exceedingly simple, it directs attention to the part 
diseased, the function impaired, and in so far as" reme- 
dies act on particular parts, it suggests appropriate 



220 STUDY OF DIAGNOSIS. 

remedies. In ordinary professional consultation it 
proves sufficient, as it does in writing, and it is quite 
sufficient to satisfy the popular demand for names. 



CENEKAL CLASSIFICATION 

i 

We will make a study of disease according to the 
four general divisions heretofore named. 1st, with ref- 
erence to the cause — epidemic, contagious, endemic, spo- 
radic ; 2d, as it is general or local ; 3d, as it is .structural 
or functional ; and 4th, as it shows a departure from 
the physiological standard. In doing this the special 
features will be so pointed out, that the reader will be 
enabled to recognize the divisions, and classify his 
cases according to them. 

It is possible that the description will be at times 
longer than is really necessary for the purposes of 
diagnosis, as we wish as far as possible to study the 
natural history of disease, but it will be made as con- 
cise as possible. 

EPIDEMICS. 

A thorough study of epidemic influences has not yet 
been made, and we know much less of the subject than 
we should. }~et what we do know has an important 
bearing upon practical medicine. J 

Many physicians have recognized the fact, that the 
conditions of life do change from time to time, and that 
as the result of this there are variations in the wrongs 
of life — diseases — and in their expression. That in 
some years and seasons, these changes were so great as 
to give that character to disease which is usually known 



STUDY OF DIAGNOSIS. 



221 



as epidemic. The fact has been recognized, that this 
epidemic condition might influence but one disease, or 
a class of diseases, as those called contagious, those 
called zymotic, or it might influence all diseases or 
pathological states. 

The general epidemic influence is known by some 
special character of disease, which is wide-spread, and 
is noticed in many localities. In some cases it will be 
seen as a condition of asthenia, in others of undue ex- 
citation. In some it partakes of the zymotic character, 
and this influence upon the blood is noticed in a 
majority of cases of acute disease. Phj^sicians will re- 
collect it under the name of typhoid, giving a peculiar 
character to fevers and inflammations, and even 
noticed in minor affections. 

This epidemic influence is frequently marked by 
special symptoms calling for special remedies. Thus 
the diseases of the Winter of '72-73 were characterized 
by a peculiar frontal pain, frequently localizing itself 
in the left orbit; a peculiar appearance of tongue, with 
prominence and redness of the papillae of the tip ; the 
tendency to erythematous redness and inflammation of 
skin and mucous membranes. Epidemic remedy—- 
Rhus Toxicodendron. The present year, 1873-74, we 
notice the common basilar pain, and the impairment 
of the venous circulation — fullness of veins, a pecu- 
liarity of pain, especially of right side, and affection of 
serous membranes. Epidemic remedies — Podopbyllin, 
Bryonia. In 1870-71, we noticed especially the deep 
coloration of mucous membranes, the tendency in 
severe disease to brown tongue and sordes. Epidemic 
remedy— Muriatic Acid. 

To diagnose this epidemic influence, one must be a 



222 STUDY OF DIAGNOSIS. 

reader of the periodical literature of the day, so as to 
see the expressions of disease in different localities. 
It is true that observations are made without reference 
to this, and the reporters do not believe in it, but the 
evidence is all the more valuable. No one can take a 
half dozen of our medical periodicals, and compare 
them for a series of years, without being struck with a 
certain similarity in the diseases of a year, or a series 
of years, which can be accounted for in no other way. 
It would be possible from our periodical literature to 
tabulate the character of these epidemic influences for 
a considerable period of time, and this no doubt will 
be done in the future. 

The reader will have no doubt observed, that the dis- 
eases of some seasons, no matter how diverse in special 
characteristics, would have something in common, 
which something would be especially manifest in the 
treatment. That in some seasons Quinine would cure 
everything, in others the sedatives would cure every- 
thing, in others a remarkable benefit from Podophyllin, 
so that when you had once determined a good treat- 
ment, you would persist in it for all affections, with 
very little modification. 

And this brings prominently before us the fact, for 
fact it is, that there is an endemic or epidemic consti- 
tution of disease, that should be well studied, and 
always regarded in treatment. Success or failure will 
very frequently depend upon this knowledge, and it ia 
something that must be relearned every year. 

It was a prominent doctrine of Eademacher and his 
followers, and he had remedies for three such constitu- 
tions. These were Iron, Copper, and the Nitrate of 
Soda. There was some truth in this, how much I don't 



STUDY OF DIAGNOSIS. 



223 



know, for I have not had the opportunity to experi- 
ment, and, indeed, have not had time to give his works 
the examination they should have, as I read German 
slowly, and they have never been translated. 

I believe, however, I have passed through one 3 r ear, 
in which Iron was the remedy for almost everything, 
and I think probabty some of our old practitioners 
may recollect it, if they by chance had used Iron. 
The season commenced in December with a large num- 
ber of cases of erysipelas, for which Iron Avas a specific, 
and for some fourteen months I prescribed Iron daily 
for almost everything, with the most flattering results. 
I have experimented with Copper and Nitrate of Soda 
to but a limited extent. 

Bademacher applied the principle to chronic disease. 
G-rauvogl says: 

" One experience gained by this school is worthy of 
special consideration — ' that, in old chronic diseases, the 
previous epidemic constitution always decides, first of 
all, upon the present indication of a remedy, hence, in 
every case which comes up for treatment, the time of 
its first appearance should be learned, as far as possible, 
for, by this, frequently, if the then epidemic curative 
remedy is known, the primary seat and the primary 
kind of the diseased process are known also, and this 
very remedy will still effect a care, if a cure is yet 
possible, or, if the disease is not already succeeded by 
another disease of the first affected organ or blood, or 
if disease of another organ has not ensued. But, even 
in this latter case, that knowledge gives the point of 
departure for the whole chronic affection.' 

" That is in gross, what we see happen on a smaller 
scale, after strong or oft-repeated doses of long-acting 



224 STUDY OF DIAGNOSIS. 

remedies. First appear symptoms at the point of 
application, then of its reception in the blood, finally, 
the affections of tho specifically affected organs and 
systems in succession, and often, at great intervals, as 
we have observed very distinctly with quicksilver, for 
instance. The only difference consists in this, that 
epidemic injurious influences, often after very many 
3 7 ears, to the surprise of many, bring to view their con- 
tinued operation as a token of the presence of their re- 
sults under various forms of disease, while the continued 
operation of drugs is of proportional^ shorter dura- 
tion." 

If this theory of epidemics is borne out by future 
observation, it must have an important bearing upon 
therapeutics. If we determine a common element in 
the diseases of a season, we will have something common 
in the remedies. If we have an underlying influence 
of this kind, giving character to disease throughout a 
considerable extent of country, it is an influence that 
should be known, and have due weight in our estimate 
of pathological processes. If we can go still further, 
and find certain epidemic remedies opposed to this in- 
fluence, whatever it may be, it will greatty aid our 
treatment. 

I am not only satisfied that we have these epidemic 
constitutions of disease, but that we have epidemic 
remedies as well. And going further than this, I 
believe with Eademacher, that this epidemic influence 
persists in chronic disease, and that the knowledge of 
the epidemic influence at the time the disease com- 
menced, may give us in the epidemic remedy of that 
year, the means of cure. 

We need not re-discuss the change of type theory, 



STUDY OF DIAGNOSIS. 225 

and yet I have no doubt but that disease does change 
its type; that for a number of years it has the char- 
acter of asthenia, and for another period it will be 
sthenic. The knowledge of this will be available in 
the selection of remedies. 

Again we find years in which the peculiar wrongs 
known as typhoid are prominent. All acute diseases 
seem to partake of this character, and if of consider- 
able duration, typhoid symptoms will be developed. 
We have "typhoid pneumonia," "typhoid dysentery," 
intermittents and remittents run into typhoid, as well 
as other diseases. This epidemic influence is readily 
recognized, and suggests treatment. 

Zymotic diseases are not unfrequently epidemic, or 
have underlying them the epidemic character. It is 
true they frequently produce a specific contagion, which 
serves as a cause of their propagation, and this we wish 
to keep distinct from the character we are now studying. 
The epidemic influence is that which renders the com- 
munity very susceptible to the contagious poison, or 
gives it specific characters, or renders it more destruc- 
tive to life. 

Eeaders will readily recall epidemics of this character, 
Seasons in which smallpox, scarlet fever, measles, 
whooping cough, were, remarkably prevalent, easily 
transmitted, difficult to protect against, possessed dis- 
tinctive features, and required special treatment. And 
they will likewise recall the fact, that in these years 
other diseases would show similar peculiarities, and 
would require similar remedies. This will have been 
noticed in local complications, as well as in the general 
features. That in some years there was a remarkable 
tendency to disease of the respiratory apparatus, or of 



226 STUDY OF DIAGNOSIS. 

the bowels, or of the kidneys, or of the nerve centres, 
and that these local affections were to be met with as 
complications of ail diseases. 

I have already noticed the fact that such epidemic 
influences maj- be discovered in chronic diseases; that 
man}' times the disease will partake to a greater or less 
extent, of the epidemic constitution of the year in 
which it was contracted, and will require the epidemic 
remedies of that year in its treatment. Indeed, in 
some cases, we find that determining this, and knowing 
the constitution of disease at the time it commenced, 
and the remedies that were curative then, we have de 
termined the remedies which will prove curative. 

It is not only important to thus be constant!}" on the 
alert to determine the presence of epidemic influences, 
and carefully note the expressions of disease at such 
times, but it is well to keep memoranda for future use 
It is true that all disease has distfnct and definite ex- 
pression, and that for this we may find distinct and 
definite remedies ; quite as much for this epidemic con- 
stitution of disease as any other. 

We are acquainted with quite a number of epidemic 
remedies, and find the list continuously enlarging. So 
marked is the influence, and so distinct the features, 
that we sometimes find a single remedy sufficient for 
the entirety of disease. It is possible that we may 
make the best study of remedies in such seasons, for I 
have noticed that if a remedy has thus proved markedly 
curative at such times, the epidemic symptoms indicat- 
ing it being pronounced, the remedy would prove cura- 
tive in sporadic, endemic, or contagious diseases, wher- 
ever the special symptoms were present. 

The remedies worthy of special notice in this con- 



STUDY OF DIAGNOSIS. 227 

nection are Quinine, Muriatic Acid. Soda, the Antisep- 
tics. Sulphurous Acid and Sulphite of Soda. Chlorate 
of Potash, Baptisia, Aconite, Veratrum, Belladonna, 
Gelseminum. Eh us Toxicodendron, Iron, Nitric Acid, 
Podophyllum. Lobelia. Bryonia, Nux Vomica. 

All of these, and such others as may have attracted 
the attention of the reader as being especially useful 
in certain years, may be advantageously studied in this 
connection. 



CONTAGIOUS DISEASES. 

In this classification we find that certain diseases are 
produced by a specific cause, generated during the pro- 
gress of the disease, and propagated from person to 
person. In them we find that the contagious element 
is continuously reproduced in kind, and the expressions 
of disease are alike. As before noticed, it may and 
does vary from epidemic influences, and as we will 
hereafter see, from endemic influences, but in general 
features there will be a remarkable likeness, and in 
therapeutics there will be something in common. 

The diseases grouped under this head are the erup- 
tive fevers — variola, rubeola, scarlatina, varicella; the 
contagious cough — pertussis — whooping cough ; some 
zymotic diseases — erysipelas, puerperal fever, diphthe- 
ria, spotted fever, cerebro-spinal meningitis ; some 
fevers and inflammations, cholera, typhoid, typhus and 
yellow fevers, inflammations with typhoid symptoms 

The general diagnostic feature is that the disease can 
be traced from person to person, and when the fact of 
exposure is known, we are justified in giving it the 



228 STUDY OF DIAGNOSIS. 

care, and using the precautions against the spread of 
contagion that may be necessary. 

These diseases have certain distinct expressions by 
which they may be known, and when we have a first 
case, the contagious element will receive due considera- 
tion, especiall} T in guarding against its communication 
to others, in some cases by the use of appropriate pro- 
phylactic means. We also regard the fact, that the 
contagion generated during the progress of the disease 
may unpleasantly influence the patient, indeed his life 
maybe destroyed by its presence with and around him. 

Variola. — The diagnosis of smallpox will be' made 
by — a, the intense, aching pain in all parts of the body, 
deep seated, during the first day of febrile reaction; 6, 
the appearance of t he eruption, as distinct red spots, 
which give to the toueh the sensation of hardness like 
a shot under the skin ; c, the regular development of 
the pustules in a period of nine days; and d, the flat- 
tened and umbilicatcd form of the pustules. 

It suggests protection by vaccination, by avoidance 
of the cause, by the use of proper antiseptics. In the 
treatment of the disease, that the contagion be removed, 
as far as possible, by the excretory organs, and at 
length by the completed stages of the eruption. When 
the contagious virus is in large quantity, as, shown by 
the nsual evidences of decomposing animal matter, it 
suggests the use of antiseptics, agents that destroy the 
material of contagion, great cleanliness, and a sustain- 
ing treatment 

Eubeola. — The diagnosis of measles will be made 
by — a 1 the catarrhal symptoms, full, suffused and in- 
jected eyes, which announce the attack; 6, the pecu- 



STUDY OF DIAGNOSIS. 229 

liar and constant cough ; and c, the irregular form of 
the eruption. 

It suggests Lobelia and Asclepias to favor the deter- 
mination of the eruption upon the skin, and relief of 
irritation of mucous membranes, and Drosera as the 
special remedy for the cough. 

Scarlatina. — The diagnosis of scarlet fever will be 
made by — a, the early appearance of a sore throat, 
which persists and is a marked feature of the disease ; 
b, the high range of* temperature, and dryness of sur- 
face ; c, the vivid scarlet redness of the eruption ; and 
d, the evident iuq^irment of the cutaneous capillaries, 
as marked by the persistent white line left as the finger 
is drawn over the surface. 

It suggests Belladonna in minute doses as a prophy- 
lactic. Belladonna and Carbonate of Ammonia as stim- 
ulants to the capillaiy circulation of the skin. And 
the use of fatty inunction alone, or with stimulants — 
Creosote and Common Salt. 

Yarioella. — The diagnosis of chicken pox will be 
made by — a, the irregular appearance of the points of 
eruption ; b : their speedy development ; and c, their 
vesicular form. 

Pertussis — The diagnosis of whooping cough will 
be made b} T — a, the occurrence of cough without febrile 
symptoms ; 6, its paroxysmal and spasmodic character ; 
and c, the whoop, the sibilant or whistling sound as the 
air is forcibly drawn through the contracted larynx 
during or at the close of the parox3'sm. 

It suggests specific remedies, Drosera, Belladonna, 



230 STUDY OF DIAGNOSIS. 

Nitric Acid, and Trifolium Pratense, as may be indi- 
cated in each case by special sj'mptoms. 

Zymotic Disease. — Whilst all contagions may be 
classed as zymoti'., all zymotic diseases are not conta- 
gious. Those named— erysipelas, diphtheria, spotted 
fever, and cerebro-spinal meningitis — maybe epidemic, 
endemic, or contagious, and we study them in each of 
these classes. When they prove contagious, it may be 
from either of two conditions — the intensity of the dis- 
eased action, or the loss of life and breaking down 
of the tissues. 

If we take the first disease, erysipelas, we will find 
that it sometimes develops remarkable virulence in this 
direction ; so much so that it will attack almost every 
surgical case in a hospital, and will be contracted by 
nurses and others. This of course will be noticed espe- 
cially in certain years (epidemic influence) and in cer- 
tain localities (endemic influence), but we can not 
neglect to notice the contagious element. 

In the one case we notice the intensity of disease, both 
as to its local and general symptoms- The part is in- 
tensely hot, burning, painful, and is dry and tense, and 
its color, whether bright or dark, is vivid. The pulse is 
frequent, tense, and unyielding, the temperature has a 
high range, and the nervous system shows great exci- 
tation. Whenever such symptoms show themselves, 
we may fear contagion, and will employ means to pre- 
vent the infection of others. 

In the second case we have the evidences of sepsis 
and deliquescence of tissue. Locally the part is full, 
and wants elasticity, the epidermis yields, and presently 
the connective tissue The discharge becomes offen- 



STUDY OF DIAGNOSIS. 231 

sive. the pulse oppressed and feeble, and the tissues at 
large softened. 

Whilst in the first case remedies would have reference 
to the intensity of diseased action, and consist princi- 
pally of the five specifics — Iron, Veratruni, Kb us, Apis, 
Belladonna; in the second it will consist in the 
use of the proper antiseptics, with restoratives and 
food. 

In the second, puerperal fever, we notice the same two 
elements of contagion, quite as marked as in erysipelas. 
But there is added a third, an infectious material 
thrown off from the reproductive organs. So marked 
and virulent is this, that it is readily communicated by 
the physician from patient to patient, even through an 
interval of days or weeks. It is not only thus infec- 
tious, but is intensely poisonous to the patient, and its 
re-absorption intensifies disease, and frequently leads 
to a fatal result. 

Having regard to the means named in erysipelas, the 
phj'sieian gives especial attention to prevent the spread 
of contagion. In some cases this may be avoided by 
strict attention to cleanliness, change of clothing, and 
the use of antiseptics, as washing with a solution of 
Chlorate of Potash, Sulphite of Soda, Labaraque's 
Solution, or dilute Sulphurous Acid. To prevent re- 
absorption, we use great cleanliness, and the antiseptics 
just named. 

In diphtheria the contagious property seems to be 
developed more by the intensity of disease, than by 
devitalization of tissue and putrescence, and it is 
always well to use extra precautions when the febrile 
action and local inflammation are intense. But here as 
in puerperal fever a specific infection is generated at 



232 



STUDY OF DIAGNOSIS. 



the point of local disease, and is readily communicable 
to others. This is so marked that the diphtheritic de- 
posit is readily inoculable, not only in the throat, but 
on almost every abraded surface. 

The knowledge of these facts will not only cause us 
to. guard against the general conditions of contagion, 
as in the other cases, but especially against the trans- 
mission of the local infection by coming in immediate 
contact with the patient and inhaling the breath, the 
use of towels, handkerchiefs, before they have been 
thoroughly purified by boiling, and especially the use 
of probangs, swabs, or surgical instruments that have 
been employed on a diphtheritic patient. 

In cerebrospinal meningitis and spotted fever we have 
the double element of contagion first named. The 
generation of the infectious material by intensity of 
disease, and by loss of life in tissues, and putrescenc t y. 
The same means will be employed as in the case of 
erysipelas, both to prevent the spread of contagion, 
and to protect the patient against the poison generated 
in his own body. 



Cholera. — Asiatic cholera might be studied in the 
class of epidemic diseases, as in the seasons of its prev- 
alence there is a marked epidemic influence, that shows 
itself in other diseases as well as this. But though we 
recognize this, the evidence that it is propagated by a 
specific contagion is too well proven to allow us to 
neglect it. Cholera advances on lines of travel, and 
renews its strength as it goes, going with people, being 
propagated by and in people. Gaining strength and 
virulence by special combination of circumstances in 
its native country India, it takes passage b} T steamship 



STUDY OF DIAGNOSIS. 233 

to Europe, from Europe to America, where it is dis 
tributcd by railroad, steamboat and stage 

It is probable that the infectious poison is found prin- 
cipally in the excretions, and mainly in the dejections 
from the bowels, and the disease is especially propagated 
from them. If so, it points the physician to the neces- 
sity of especial care in the removal of the dejections, 
and that they be so disposed of as not to endanger 
others, either by their exhalations, or by contaminating 
the water supply. 

We diagnose an attack of cholera b}^ — o, the great 
exhaustion that attends the first discharges ; b, by the 
evidences of imperfect circulation and aeration of the 
blood, as seen in the bluish discoloration of the ex- 
tremities ; c, by the want of color in the faeces, "rice 
water"; d, by the marked enfeeblement of the circu- 
lation, and lowered temperature ; and e, by the exces- 
sive thirst, nausea and vomiting, and muscular cramps. 

Typhoid Fever and acute diseases assuming typhoid 
symptoms, usually possess the contagious element in 
slight degree. Yet in some cases we observe a remark- 
able development of this character which demands the 
attention of the phj^sician. Typhoid is generally 
thought to mean asthenia, but it is better to think of it 
as having reference to sepsis of the blood. With the 
condition of sepsis, comes the property of contagion, 
and under some circumstances this becomes marked. 1 
think diseases called typhoid will be found to develop 
the character of contagion both from intensity of dis- 
ease, and from impairment of the life of tissue and 
putrescence. The most marked cases I have known 
were when there was great nervous excitation, tense 
20 



234 STUDY OF DIAGNOSIS. 

tissues, high temperature, and the sensation of pungent 
heat when the hand was applied to the surface. The 
other cases are distinguished by a peculiar sweetish 
cadaveric odor of breath, dark fetid faces, and fetor of 
urine. 

Typhus Fever is markedly contagious, and may be 
wholly propagated b}^ a specific contagion generated 
during the progress of the disease, and thrown off in 
the excretions both from bowels, kidneys, skin and 
lungs. It has been noticed that here intensity of dis- 
ease, marked by great febrile excitement, was more 
likely to develop the contagious element, than the con- 
dition commonlj' known as putrescence. 

Yellow Fever is undoubtedly contagious in degree, 
sometimes very markedly, and at others so as to exert 
but little influence. Both conditions of contagion have 
been noticed: that from great intensity, of disease, 
with the symj)toms heretofore named, and from putres- 
cency appearing in the last stage with the black vomit. 



ENDEMIC DISEASES. 

If disease showing distinct peculiarities is confined 
to a locality*, it is said to be endemic, especially if it 
prevails to any considerable extent. In such cases the 
cause is evidently local, and it is evident that many 
times it may be discovered,. removed, or avoided. 

These diseases have a definite and distinctive expres- 
sion, which should and may suggest the means of cure. 
In some the endemic influence is so wholly the cause, 
and the endemic expression so clearly indicates the 



STUDY OF DIAGNOSIS. 235 

lesion, that remedies will be remarkable for their cura- 
tive influence. At other times the endemic influence, 
and disease produced, will be but apart of the wrong, 
and whilst the endemic remedies are important, they 
are not so certain as before, and have to be aided by 
other means. 

The diagnosis of endemic disease is usually very 
clear: a. There is something distinct and special in the 
expression of disease ; b : there are a number of cases, 
showing these special features ; c, the diseases are re- 
stricted to definite localities. 

First among the diseases included in this classifica- 
tion are all those showing periodicity, including inter- 
mittent, remittent, and yellow fevers. Following these, 
we find that an endemic influence may give rise to the 
series of continued fevers, to all inflammations, and to 
many functional and structural diseases. And it is to 
be noticed that as a rule the endemic influence intensi- 
fies the natural disease in addition to giving it special 
features. 

Periodicity. — Whatever maybe the cause of period- 
ic^ in disease, the fact is sufficient^ tangible, easily 
recognized by the periodic expression, which indicates 
a special pathological condition, and calls for a special 
group of remedies, anti-pcriodics — Quinine. As before 
remarked, the periodic element may serve as a basis of 
nearly every named disease, which will be cured b}^ the 
one remedy, Quinine. Or it may only be a complica- 
tion, or part of the disease, and Quinine will onty be 
one of the remedies called for. But periodicity does 
not alwaj^s mean Quinine, and it is sometimes difficult 
to determine whether it does or not. All diseases are 



236 study or diagnosis. 

periodic to a certain extent, having periods of increase 
and diminution, as ma}' be noticed even in the fevers 
called continued. Indeed all the functions of life, both 
in health and disease, have something of periodicity in 
their performance. 

The diagnosis of periodicity will be made by — a, The 
marked remission or intermission of the evidence of 
disease, and return to the healthy standard of life ; 6, 
the' equally marked exacerbation of disease, especially 
with reference to the wrongs of innervation, tempera- 
ture and circulation ; c, the disposition to continue such 
functional aberrations without change of structure; and 
d, the fact that such disease is endemic in the locality. 

Intermittent Fever. — We diagnose an ague b} T — o, 
the marked cold stage; b, followed by a hot stage; c, 
a sweating stage — all occupying a comparatively short 
time, usually less than twenty-four hours ; and d, a 
more or less complete intermission of the disease, and 
return of normal functional activity. 

If the intermission is complete, with normal temper- 
ature, normal circulation, innervation and secretion. 
Quinine will be the remedy. If functional wrongs 
should persist during the intermission, appropriate 
means should be employed for their removal, and the 
Quinine given if the disease persists. 

Remittent Fever- — We diagnose remittent fever by 
— a, A forming stage which may be brief or of one or 
two weeks duration, and which is frequently attended 
hy gastric disturbance, and frontal pain ; b, a chill, not 
nearly so intense as in ague, but well marked ; and r, a 
hot stage which is distinctly broken up into remissions 



STUDY OF DIAGNOSIS. 237 

and exacerbations, and continues to the sweating stage, 
which is the termination of the disease. 

The distinct remissions and exacerbations— periodi- 
city — means Quinine, and in some cases this remedy 
will be sufficient to arrest the entire series of morbid 
processes. This condition will be known by— a, The 
soft and open pulse; b, the moist, and cleaning tongue ; 
c, the soft and moist skin; and (/. return of normal in- 
nervation — at the remissions. If these conditions' do 
not present, we determine the character of the wrongs 
and employ the means necessary to remove them 

Yellow Fever. — -Though there is undoubtedly an 
epidemic influence in some seasons, and the disease is 
more or less contagious, we find that the endemic con- 
ditions are of great importance. Yellow fever can not 
prevail in unfavorable situations, (it is said never to 
prevail at altitudes of more than four hundred feet 
above the ocean), and just in proportion as the local 
influences favor it, the disease will be severe and fatal. 
Bad drainage and want of cleanliness are especially 
noted as likely to favor the propagation of yellow 
fever. 

The diagnosis of yellow fever is made by— a, The 
marked chill, attended by lumbar and frontal pain, 
nausea and vomiting; b, the rapid accession of the hot 
stage which is very intense, lasting from twenty-four 
to seventy-two hours ; c, the abatement of febrile ac- 
tion, but with marked prostration, and gradually in- 
creasing yellowness of skin ; and d, the return of nau- 
sea and vomiting — the black vomit. 

Typhoid — Next to periodicity the most frequent and 
marked endemic influence is that which gives the 



238 STUDY OF DIAGNOSIS. 

typhoid character to fever. It may produce typhoid 
fever with disease of Peyer's glands, may cause typhoid 
symptoms in remittent fever, and all the inflammations. 
A very common manifestation of the influence is in 
typhoid dysentery, and typhoid pneumonia. The local cause 
is evidently decomposition of vegetable and animal mat- 
ter, the products being thrown off into the air and in- 
haled, absorbed by food, or infecting the water supply. As 
it is possible to remove such causes, the physician should 
always direct attention to them in these cases, that they 
may be removed. 

Using • the word typhoid as an adjective to designate 
a condition of disease, it has reference to the condition 
of sepsis and putrefaction. The enfeeblement or asthe- 
nia is but an incident, and is sometimes not noticed 
until a late stage, though the typhoid symptoms are 
marked. 

The diagnosis is best made by examirjing the exuda- 
tions or secretions. It is especially marked in the 
mouth ; on the tongue by dirty coating, or a fur that 
assumes a brownish tinge and gradually becomes deeper 
until it is almost black ; dirty or dark hordes upon the 
teeth ; unpleasant, dark, and offensive faeces ; urine 
that is frothy, and gives an unpleasant cadaveric odor. 
We also notice it in the sense of pungent heat when 
the hand is applied to the surface, and in the low de- 
delirium. In surgical diseases, the discharge from 
wounds or injuries, or operations, will show it. in a 
wrong of the pus, which becomes thin, ichorous, fetid, 
and in a tendency to softening of tissues and sloughing. 

It suggests the class of antiseptics, especially Sulphite, 
of Soda, Sulphurous Acid. Muriatic Ac*d Otiiorate of 
Potash, and Baptisia. which are selected vcordm^ tc 
special indications hereafter named. 



STUDY OF DIAGNOSIS. 239 

We also find special expressions of disease, when 
endemic, that indicate special remedies, and these prove 
curative. As in the case of epidemic influence, we find 
that these symptoms are common to many or nearly all 
the diseases of the season or year, and the remedy in- 
dicated assumes a very prominent place in treatment. 
Thus all the remedies named as bein^ indicated in 
epidemics, are found indicated when the cause is 
endemic. 

Thus we sometimes find an erysipelas, puerperal 
fever, or dysentery, that is clearly endemic, and the 
special indications for remedies will be distinct. We 
want Iron, Veratrum, Ehus, Podophyllin, etc., and the 
indications are so direct and positive that a cure is cer- 
tain and speedy. 



SPOEADIC DISEASE. 

In this last class we find no special expression of 
disease, or in other words, we find the regular succes- 
sion of symptoms as given by authorities. The causes 
are in the acts or indiscretions of the individual, in ex- 
posure to heat, cold, wet ; want of proper clothing or 
protection ; intemperance in eating and drinking ; over- 
exertion, physical or mental — and the reverse, a want 
of exercise. Or the cause may be found in the general 
conditions of life ; sudden changes of temperature ; 
more or less moisture in the atmosphere ; and a greater 
or less electrical condition. 

These causes are temporary, and avoidable, and it is 
well to study them in relation to disease. Whilst a man 
may not escape an epidemic, contagious, or endemio 



^^™ 



240 STUDY OF DIAGNOSIS. 

cause, right living will usually prevent the class of dis 
eases called sporadic. 

It is also well to notice that these diseases are usually 
simple in their structure, and very amenable to reme- 
dies. If we take the physiological stud} 7 of disease, 
and determine which is the^vs^ wrong of Junction, and 
right it, Ave will have but little trouble in treatment. A 
sporadic fever yields readily to the special sedatives — 
agents that rectify the wrongs of the circulation ; or at 
farthest will need but the help of those which increase 
secretion. An inflammation readily yields to the gen- 
eral sedatives, and those which- remove the irritation of 
the part. The important points to determine in these 
cases are — the character of the general disease, and 
the remedies which will right it; the situation and 
character of the local disease, and the remedies that 
will influence the part, and influence it in a right direc- 
tion. 

GENERAL AND LOCAL DISEASE. 

This would seem to be a very simple and profitable 
classification, both in determining the character and 
gravity of disease, and in selecting remedies. Yet 
when we come to the bedside we find it vevy difficult 
to make the diagnosis. Disease may be so uniformly 
distributed, that it is impossible to say that one part 
suffers more than another, or it may be so localized 
and restricted to a part, that its general influence is 
hardly noticed. Yet in most cases we will find the two 
associated together. It is difficult to find a person so 
uniformly constructed that there is not some weaker 
part, and in disease which otherwise would be general, 



STUDY OF DIAGNOSIS. 241 

this weaker part suffers. If it were not so, the happy 
man would be like Dr. Holmes' ; ' one horse shay," and 
like it would fall to pieces at once, somewhere between 
three score ai)d ten and five-score years. And there 
is no part so disconnected with the organism as a 
whole, that can suffer disease without influencing the 
body at large. 

Though the body, so varied in function, is one, yet 
it is of advantage to think of disease as being general 
and local (in principal part), and associate with these 
ideas thoughts of general and local remedies. To get 
a fair conception of the elements of general disease it 
is well to think of those functions which are common 
to the entire man, or which are equally necessary in 
their rcsujts to the entire man. And to get a fair con- 
ception of local disease, we study the function of each 
part, in so far as it can be dissevered from the life in 
its totality. 

We might make a group of the elements of general 
disease, according to our physiological classification, 
somewhafas follows : 



i ^ectncity.{ Condition9 of life and motion. 



{Formative — for organization. 
Heat. 
Electricity. 

{Increased, 
Diminished, 
Wrong in kind. 

The Blood. I In its organization. I with "fiwenpe to nutrition, to degenera- 
( tions, deposits and growths. 

f Retained excreta. 



Influenced by \ Malaria. 

J j Zymotic poisons 
[.Specific poisons. 



.Specific poisons. 
( For the supply of Oxygen. 
Trie Respiratory Function.^ For the removal of Carbonic Acid. 
CAs an aid to the circulation, 
f From the sympathetic, co-ordinating the vegetative process. 
| From the spinal cord, as influencing the automatic function?-. 
Innervation. <( f Reason. 



■{ ( Reason. 

[Fron* theB -MvoTt! o r 
(Sensation. 

23 



242 STUDY OF DIAGNOSIS. 

It is not necessary to consider each of these in this 
place, but having them grouped before the eye, the 
mind can analyze each one as a factor of disease, and 
combine them in natural groups, as usually seen. The 
mind not only recognizes them as general elements of 
disease, but will soon learn to recognize the common 
expressions of wrong, according to the classification of 
excess, defect and perversion. And it will soon go further 
than this, recognizing remedies which reach each in- 
dividual element, and do that necessary to be done — 
opposing the morbid action and influencing the func- 
tion toward the normal standard. If there is an ex- 
cess — above, the influence is to bring down to the stand- 
ard of health. If there is a defect — below, the influ- 
ence is to elevate or bring up to the normal standard. 
And if there is a perversion — a departure from, the in- 
fluence is to bring back to the normal standard. 

We have already noticed that none of these elements 
of general disease can exist without producing more 
or less of local disease, and we may also say without 
influencing the entire series named. With reference 
to local disease we find it severe and destructive in 
proportion to -the severity of the general lesions. So 
too we find that the influence of some of these elements 
of disease sets up a series of lesions which are severe 
in proportion to the severity of the original one. In 
both cases general remedies are most important, and in 
so far as they rectify wrongs, and restore normal struc- 
ture and function, they are most important. 

In some cases the general lesion determines tho 
character of the local one. This is especially the case 
when the general lesion is Of the blood, giving caco- 
plastic or aplastic deposits-. An inflammation may 



STUDY OF DIAGNOSIS. 243 

spring" up, simple in its character, from the common 
causes, and if there had been no wrong of the blood, it 
would have readily passed away by resolution. Yet, 
there being cacoplastic material in the blood, this is 
thrown out as an exudation, and breaking down, causes 
most serious destruction of tissue. If in such cases as 
this the character of the general lesion were recognized 
early, and proper means employed to remove the im- 
perfect material by way of the excretory organs, and 
so improve digestion and blood making as to prevent 
its renewal, the local lesion would be less severe and 
destructive. In place of a " white swelling," or " mor- 
bus coxarius," the inflammation would run its regular 
course of six to nine days to resolution. 

If we take the case of phthisis pulmonalis, we find 
another good example. Say there was an original want 
of formative force, and in consequence there is continu- 
ously produced an imperfect material in the blood. 
Its deposit in the lungs comes whenever from any cause 
excretion is arrested, preventing its normal removal, 
and when an irritation of and determination of blood 
to the lungs is set up — the material being carried to 
the lungs and there excreted. In this case a rational 
practice of medicine looks first to an increase of forma- 
tive force, getting thereby a better blood, better tis- 
sues, and a stronger life. When the disease has once 
developed itself, the treatment will of course look to 
the establishment of the processes of combustion and 
excretion — removing the material from the blood in 
this way — and the arrest of irritation of the lungs, 
which is the cause of the deposit there. 

If we take the single factor, heat, as the example, we 
find the very same state of affairs. If, for instance, we 



244 STUDY OF DIAGNOSIS. 

have the lesion of the "blood known as " typhoid," we 
find that its increase is in proportion to the wrong of 
the temperature. If we have an inflammation of the 
lungs, the local disease is destructive in proportion to 
the increase of temperature. If we have a phthisis 
pulmonalis. the deposit is rapid in proportion as the 
temperature is high, and the destruction of lung tissue 
is in the same ratio. We say, therefore, that diagnosis 
by the body thermometer, must suggest a class of gen- 
eral remedies, which will prove efficient in modifying 
and arresting general and local disease. 

There is no doubt but that lesions of excess and de 
feet of electricity, as a condition of life, and as a force, 
have a similar influence upon disease. Plus electricity, 
and we have increased disease by excitation; minus 
electricity, and we have increased disease oy want of 
excitation. The diagnosis will be formed in most cases 
by the degree of excitation as manifested by expres- 
sion, and the proper remedies will suggest themselves 
to relieve the body of its superabundance, or to employ 
means which will add to. or prevent its waste. 

When Ave stud}' the circulation of the blood as a 
factor in disease, we see how marked the influence of 
one of these general wrongs. Given a lesion of fre- 
quency in movement only, and we find that any morbid 
process is increased in proportion. Secretion is 
arrested, the appetite is lost, blood making and nutri- 
tion are impaired, waste is interfered with, and every 
cause of disease intensified. Wrongs in the circulation 
other than frequency, give the same results. Even an 
unequal circulation of the blood may lead to such 
serious impairments of function, as to be a cause of 
death Evidently the diagnosis of these general 



STUDY OF DIAGNOSIS. 245 

wrongs, and the use of remedies to reach them, are of 
prime importance. 

When we study the influence of lesions of the circu- 
lation upon local disease, we find them playing the 
same important role. If you have a local disease, in- 
flammatoiy or otherwise, it will be to a considerable 
extent severe and destructive in proportion to the 
lesion of the circulation. If we have an inflammation 
of the lungs, it will be severe in proportion to the fre- 
quency and wrong in the circulation. With a pulse of 
100 beats per minute, and free, there is little danger ; 
but with a. pulse of 130, small and sharp, there is most 
serious danger. If in such case, the lesion of the cir- 
culation can be removed, the local disease will be modi- 
fied in the same proportion 

Continuing on with this classification, attention 
might be called to the next group — the blood influenced 
by certain causes of disease. Take first retained ex- 
creta, and we have a most excellent example of the 
need of diagnosis by this classification. We are treat- 
ing an injury, a wound for instance, and everything 
progresses well, until from some cause one or more 
secretions are arrested. At once we see a change in 
the local disease, the part suffers, its temperature rises, 
becomes painful, the process of repair stops, the exuda- 
tion is changed in character, the pus is unpleasant, and 
finally the repair accomplished is broken down, and it 
may be the part sloughs. Surely it is well to be able 
to recognize this wrong, and bring such means to bear 
as will re-establish waste and excretion. 

Or a person from some common cause may have a 
simple fever. At first there are no unfavorable symp- 
toms, and we reasonably expect a speedy convales- 



246 STUDY OF DIAGNOSIS. 

cence, but from sonic cause there is arrest of secretion, 
which is retained in the blood. All the febrile symp- 
toms are increased, and in addition we notice in the 
brown tongue, sordes, etc., the evidence of sepsis of the 
blood. Here it is well to recognize the importance of 
this general clement of disease, and by early recogni- 
tion prevent the unpleasant consequences named. 

Malaria has played a most important part in disease 
and the reader will at once recognize its importance. 
Given a case of disease, most simple in form, seemingly 
and with this element characterized by periodic^, the 
disease may go on from bad to worse, until possibly, 
death results. It does not make much difference 
whether it is a fever, an inflammation, or some other 
disease. If we fake inflammation of the lungs, the re- 
cognition or non-recognition of this element of disease 
(periodicity), may be that upon which the life of the 
patient depends. Without remedies directed to this 
special element, the disease goes on to destruction of 
the lung tissue. With Quinine properly administered, 
it runs a brief course, and terminates in resolution. 

The influence of zymosis is well illustrated by ery-" 
sipelas. You notice the swollen, red. and glistening 
spot on the skin, and as the patient complains of the 
peculiar burning, you call it eiysipelas. If j^our atten- 
tion is not called to the element, zymosis, by the pecu- 
liar tongue, pulse, condition of innervation, etc., and 
you prescribe empirically at a local inflammation, you 
may lose your patient. Eecognizing the zymotic char- 
acter of the disease, and uniting it with proper reme- 
dies for this, the patient gets along well. 

Dysentery is another excellent example of this. In 
the minor sporadic cases, Podophyllin to catharsis. 



STUDY OF DIAGNOSIS. 247 

White Liquid Physic, or Castor Oil and Turpentine, 
may serve the purpose, and the sufferer gets well after 
a time. But do not trust zymotic dysentery to this 
treatment. Here the wrong of the blood, working 
typhoid symptoms, is the principal factor of the disease 
and the element of danger. It is to be met by specific 
epidemic remedies, or those which we class as ant'i- 
zymotic or antiseptic. 

The influence of specific poisons well illustrates the 
truth of what has just been said, though the illustra- 
tion is outside of ordinary practice. The hunter in the 
Carolina mountains feels something prick his leg, and 
getting through the brush he pulls up his pants, and 
finds but a slight wound, and the smarting has already 
ceased. It amounts to but little as a wound, but if he 
has heard the rattle of a serpent, or has seen it in the 
act of striking him. he is at once awake to danger. 
He has made specific diagnosis, and by sucking the 
wound, the use of Ammonia, or the free use of Whisky, 
he provides against the specific poison. 

We get a practical example of these lesions in the 
case of syphilis. A man finds a small sore on his penis, 
which as yet has given him no annoyance, and if he 
had no experience with such things, he would expect it 
to disappear as rapidly as it came. But as days go by. 
it gets larger, and seems more prominent, and after a 
time comes skin disease, sore throat, falling of the hair, 
iritis, nodes, etc. Surely there is something more than 
a simple abrasion here — from a strain. Supposing the 
physician should only recognize it as a sore, ignoring 
the specific poison of syphilis, what would be the suc- 
cess of treatment? And yet he could do this with 
quite as much credit, as to fail in recognizing the 



248 STUDY OF DIAGNOSIS. 

specific wrongs in zymotic dysentery, in typhoid fever, 
in smallpox, in scarlet fever, or in measles. 

If we study the function of respiration in its influ- 
ence upon processes of disease, we reach the same re- 
suits. With wrong respiration, every other wrong is 
intensified; witli right respiration ameliorated. There 
is such a thing as too much oxygen, and consequently 
increased burning and excitement, just as there is such 
a thing as blood loaded with carbonic acid gas, and so 
burdened that the varied functions of the body can not 
be properly performed. Surely it is worth our while 
to endeavor to diagnose these conditions, and to em- 
ploy remedies which directly reach the wrongs and re- 
move them. 

When we study the lesions of innervation, we are 
impressed with their influence upon all parts of the 
body, and the necessity of directing the mind to them 
in all forms of disease for the purpose of diagnosis. 
Whether our senses will detect a lesion, frequently de- 
pends upon our method of thinking. If the mind 
directs the necessary examination, the evidences of dis- 
ease may be quite clear, when otherwise they would 
scarcel}^ be noticed, and would not make the necessary 
impression. 

If we study thoroughly the physiology of the sympa- 
thetic nervous system, and get correct ideas of its con- 
trolling influence over all the functions of vegetative 
life, we will always direct our observation to those ex- 
pressions of disease which give information with re- 
gard to this. Remedies influencing disease through the 
sympathetic are among our most important therapeu- 
tic agents, and fortunately the exjn'essions of disease 
are quite clear. If we commence with the lesions of 



STUDY OP DIAGNOSIS. 249 

the circulation — frequency of pulse, change in its char- 
acter — lesions of temperature, change in the condition 
of the skin, some changes in muscular expression, 
change in the respiratory function, we will find a group 
of symptoms that are distinct and expressive, and so 
closely associated with individual remedies, that the 
remedy is at once suggested by the symptoms. 

The influence of lesions of spinal innervation is well 
shown in many cases of chronic disease, where "spinal 
irritation " is a complication. A disease of the diges- 
tive or urinary apparatus may seem quite clear and 
simple — one that remedies will readily reach, and }^et 
when we prescribe them, there is continued failure. 
We have failed to recognize a ' ; spinal irritation," but 
from this wrong of innervation, the local disease is 
continuously kept up. If the special wrong is diag- 
nosed, and proper means used for its relief, the reme- 
dies which had before failed with the local disease, are 
more speedily successful. 

We £>et another good example of this in some cases 
of continued fever, and other low forms of disease. A 
patient is doing well enough, other than he can not 
sleep from difficulty of respiration. When awake the 
respiratory function is carried on by the influence of 
the will, but when this is in abeyance, the automatic 
function of the spinal cord is not sufficient. Unless 
this wrong is recognized, and means employed to rectify 
the wrong of spinal innervation, the patient will prob- 
abh T die. We may get evidence of similar wrong, in 
one case in retention of urine, in another case in incon- 
tinence, in a third in convulsions or muscular wrongs, 
and in all we are impressed with the importance of 
remedies that influence the spinal cord, and influence 



250 STUDY OP DIAGNOSIS. 

it in the direction of health. It would be most absurd 
to omit from our diagnosis the evidence of a convulsive 
tendency, and it would be quite as absurd to omit to 
look after and recognize any evidence of spinal lesion. 

When we study the functions of the brain, we find 
them exerting similar influences over the body at large, 
both in health and disease. It will not do to under- 
value a right action of the mind, as an element in the 
recovery of the sick, as it will not do to undervalue a 
wrong action of the mind in perpetuating disease, 
(riven a mind at ease and restful, and a patient may 
recover from disease or injury, which under other cir- 
cumstances would most certainly be fatal. So true is 
this that we are ahva) T s on the watch for symptoms 
shadowing forth the condition of the brain. The quer- 
ulous voice, the hopeless voice and expression, the 
unstable voice, the tone of excitation, the tone of pros- 
tration, all convc}' valuable information, which must 
not be neglected. 

We find cases in which an emotional wrong may 
originate or so intensif}^ processes of disease as to en- 
danger life. A very familiar example of this is found 
in nostalgia, or " home-sickness." In the late war, it 
was found that this so influenced disease in the hospi- 
tals, at times, as to double the mortality ; indeed, many 
times a furlough to go home was the onty reprieve from 
death. In the recent Franco-German war, many cases 
were noticed. Fernand Papillon writes : "During the 
last war nostalgia carried off man} T sufferers among our 
unhappy prisoners dispersed throughout Germany, It 
attacked the soldiers and mobiles during the seige of 
Paris, especially toward the close of it, when privations 
and successive defeats began to reduce the most robust 



STUDY OF DIAGNOSIS. 251 

organizations." I have seen just such cases in private 
practice, and the hope and promise of a return to home, 
was the strongest remedy toward recovery. 

l - Hope is an anchor " for many wearied and suffering 
souls, binding them to this world, lightening their suf- 
fering, and giving increased strength for recovery. 
The want of hope is one of the most serious things we 
have to contend with in disease. To give hope to the 
sick, is one of the man} 7 duties of the physician. 

It is possible that some may give little credence to 
the statements regarding the influence of the emotions 
in disease. And yet every one practicing medicine for 
some years will have seen the influence of love, fear, 
anger, grief, etc., so clearly manifested, that there can 
be no mistake in the matter. I have seen grief so pro- 
found, that every function of life was seriously im- 
paired, and unless the current of thought could be 
changed, there was danger to reason or life. A free 
outburst of tears might give relief to the overburdened 
heart (brain.) 

Every physician in active practice has realized the 
influence of the will upon disease, and ever}' one will 
wish to know the condition of this function in serious 
or protracted disease. The evidence of a strong will, 
and intention to get well, is a real encouragement to 
the physician, as the want of will in this direction is a 
great discouragement. If we recognize a want of voli- 
tion in severe or protracted disease, we do all we can 
to call it out and strengthen it, and in so far as we do 
this our patient is benefited. Even in the treatment 
of a cough we find this is important. If the patient 
can be impressed with the importance of controlling 
the cough by the will, we will find it much easier to 
check it. 



252 STUDY OF DIAGNOSIS. 

Physicians are always awake to wrongs of sensation, 
though frequently the only idea that follows is, the use 
of means to obtund the sensibility of the brain. It is 
true that unpleasant sensations or pain intensify pro- 
cesses of disease, and wrong the entire body by depriv- 
ing it of necessary rest, yet many times far less harm 
comes from this than we would suppose. Indeed, in 
the larger number of cases it is better that the patients 
suffer pain, than that they be relieved by the ordinary 
narcotics. If b} r the study of pain we can select a 
remedy for disease, then it becomes a valuable evidence. 
A remedy in this case looks not so much to the removal 
of the pain, as to the arrest of the disease of which 
pain is a symptom. 

The study of local disease becomes important in that 
it directs the mind to limited parts and functions, and 
thus specializes the wrong. We group the most im- 
portant functions of the body, as of digestion, circula- 
tion, respiration, excretion, etc., and then study each 
particular organ or part. If we take digestion, we 
study the function in the mouth, the stomach, the large 
and small intestine, and as influenced by liver, pancreas, 
etc. If a certain group of organs or parts do a par- 
ticular work, we will find diseases of it announced by 
wrongs of that work. Thus the wrongs of function 
point us to the locality of the lesion, and a closer ex- 
amination determines the particular part or organ in- 
volved. 

Knowing the lesion of function we readily determine 
its influence upon the life in its totality, and upon 
other parts and functions. It is possible in some cases 
to provide against these influences, by calling into ac- 
tion other functions which may be supplementary or 



STUDY OF DIAGNOSIS. 253 

vicarious. As for example, if the digestive organs are 
in such condition that they can not appropriate calori- 
facient food, we may for the time being use alcoholic 
liquors, which require no act of digestion to furnish 
heat, until food can be taken. Or in similar cases, re- 
quiring histogeneticfood or the stimulus of beef-essence, 
we employ it per rectum. 

\\ r e have similar examples in the relation between 
the excretory organs — kidneys, skin and bowels. If 
the function of one is impaired, or there are special 
reasons why one organ should have rest, Ave call upon 
one or both the others, to do additional work. In some 
of these cases, the vicarious action will free the blood 
from noxious materials, and thus give a chance for re- 
covery. In others, the relief of the part from work, 
gives an organ opportunit} T to recover its normal con- 
dition by improved nutrition. 

In the study of local disease we not only have in 
mind the influence of changed function, but also that 
which may arise from a change in the circulation, in- 
nervation, and nutrition of a part. We can not have 
an excess of blood in a part, without depriving some 
other part of blood. "We can not have a too rapid cir- 
culation in a part, without influencing the circulation 
at large. We can not have an arrest of circulation in 
apart, without impairment of that blood, and a wrong 
to the whole of this fluid. We can not have a wrong 
of innervation of a part, without suffering of the nerve 
centres and a reaction upon the body at large ; as we 
can not have a wrong of nutrition, or waste, without 
general suffering from it. 

As the mind grasps these varied factors of disease, it 
is better able to appreciate the present condition, and 



254 STUDY OF DIAGNOSIS. 

provide against other phases of disease. We hoc only 
want to know the condition of disease at the present 
time, but we also wish to know, from this, what will be 
the probable condition to-morrow, or some subsequent 
time. If to-day we can arrest the wrongs of life now 
present, and turn the tide toward the standard of 
health, well. If not. we wish to make provision, so far 
as we can. against the wrongs of to-morrow or next 
week. 

Further along, we will give the diagnostic features 
of the general lesions here named, as well as the more 
important evidences of local disease. The object in 
this chapter being specially to direct the mind to the 
advantages of this classification, in determining the 
real nature of disease, and as being suggestive of cer- 
tain classes of remedies. As before stated, there are 
many lines of thought in diagnosis, and we do not wish 
to get them tangled. We wish to do our thinking 
methodically, and in so far as we can. we take one at a 
time. 

PHYSIOLOGICAL DIAGNOSIS. 

Some may think the heading of this chapter a mis- 
nomer, as they can not harmonize the name physio- 
logical, which means right life, with disease, which is 
wrong life. But if we explain that in diagnosis we 

must have a standard to measure from — that is. health. 
— then the term. " physiological diagnosis." is most 
appropriate, The most important element here is the 
point to measure from ; without this, diagnosis would 
be the merest guess work. 

It might be asked, how we can harmonize this method 



STUDY OP DIAGNOSIS. 255 

with the diagnosis by, unci prescription for special 
symptoms, as described in the first part of this work? 
If remedies are indicated by special expressions of dis- 
ease — symptoms — which may be common to many and 
different pathological conditions — why not employ this, 
to the exclusion of all other methods? If it is true to 
any considerable extent, should it not be true in all 
cases, and furnish the only sure basis for therapeutics? 

These are pertinent questions, and I doubt not manjr 
readers have asked them time and again. If a certain 
pain in the left orbit, a certain appearance of the 
papilla of the tongue, and a. certain sharp stroke of the 
pulse, says to us that Rhus Toxicodendron is the 
remedy, whether the disease be fever, inflammation of 
the lungs, conjunctivitis, diarrhoea, or erysipelas, what 
do we want of a pl^siological standard? True, in 
such cases we do not want it as a basis for prescription, 
and if we know enough of the relation between reme- 
dies and disease, we should not make this a study, at 
least not as a basis for prescription. But, unfortunately, 
we do not know enough of this. As far as we know 
it, we base our therapeutics upon it; when it fails, we 
must supplement it with other methods. Practical 
medicine is in its infancy, and until it attains the firm 
step of adult years, we must second it with all the aids 
that can give it support. 

If the reader will refer back to page 216, he will find 
a table which will serve as the ground-work for this 
study. We purpose examining the various functions 
cf the body, setting up a physiological standard — health 
-r-and measuring from it. We find that all lesions 
can be grouped under the three heads of — excess, defect 
and perversion — above, below, from. If once we are 



256 STUDY OP DIAGNOSIS. 

able to recognize these departures, and have a knowl- 
edge of the action of remedies upon function, we may 
make a rational selection. If the condition of disease 
is 'above" the normal standard, we employ those 
means which will bring it down. If the condition of 
disease is t: below" the normal standard, we employ 
those means which will bring it up. If the condition 
of disease is a departure u from " the normal standard, 
we emplo}- those means which will bring it back. 

The reader will notice that it makes no difference 
what " school " of remedies is prescribed from, as it is 
quite as well adapted to the one as another. Take the 
gross dose of regular medicine, and the physician using 
it should know the locality of its action, and the quality 
of its action. And even when the action is secondary 
or indirect, this method of ])rescribing is still good, for 
the mind associates tins secondary influence upon a part 
or function with what nce<is be done to restore health. 
If the modern Eclectic prescribes the usual dose of 
sjDecific medicine, he has clearly in view its direct ac- 
tion upon a part or function, and he associates the 
action of the drug with that which needs be done to 
oppose disease, and restore health Our Homoeopathic 
brother, with his minute doses or infinitesimals, fre- 
quently prescribes on the same basis. He knows vhere 
the disease is. and he prescribes a remedy which spe- 
cially influences that part; he knows the character of 
the disease, and he prescribes remedies which his expe- 
rience has shown opposes the disease, and favors the 
return of health. 

Having thus shown the advantage of this stud}^ as 
being applicable to all systems of therapeutics, and 
even adapting itself to each individual expression, I 



STUDY OF DIAGNOSIS, 257 

desire to call attention to its value as a training for the 
mind, and a study of the phenomena of life. "Think- 
ing in straight lines " has been our motto, and most 
certainly this is such method of thought. As we edu- 
cate the mind, so it will do our work, and this I think 
one of the best studies. This is a study of life in all 
its phases. It is a study of normal life, for without 
this it has no basis. And it is also a critical study of 
wrong life in all its phases, for this is its end. 

It m;iy be well to call attention again to the too com- 
monly received methods of examination and diagnosis 
— direct and by exclusion. In direct diagnosis the 
symptoms are marked and point directly to the locality 
and character of the wrong. But in some cases there 
are no such direct symptoms, and we proceed to make 
an analysis of the life before us, questioning each par- 
ticular part or function, until we have found the seat 
and the quality of the lesion. This is diagnosis by ex- 
clusion. 

Formative Force. — The force of organization is re- 
ceived by inheritance, and the rule reads — as is this 
force in the parents, so will be its manifestation in the 
children. Thus it is sometimes an important element 
in diagnosis, to know the parentage, and in so far as 
we can, their physical history. From feeble parents 
we usually expect feeble children. From parents who 
have had an imperfect organization, and wrongs of 
blood, degenerations, deposits and growths, we expect 
children with like imperfect organization, and with the 
same tendency to disease. If we know that parents 
have died of phthisis pulmonalis, or other tubercular 
disease, a cough or articular irritation has a deeper 
22 



258 STUDY OF DIAGNOSIS. 

signification, and we are wide awake to the necessity 
of early means for protection. 

If parents or near relations have bad cancer, we view 
with suspicion any growth that may make its appear- 
ance. If they have suffered with Bright's disease, 
diabetes, epilepsy, insanity, or other similar disease, we 
are advantaged by knowing the facts. 

The force of organization is very rarety in excess, 
probably never, as regards the whole man. Once in a 
while we notice examples. of it as affecting parts. Thus 
we maj^have hypertroph}- of the adipose tissue ; hyper- 
troplry of bone ; of the epithelium ; of cellular tissue, 
taking the form of growths. All of these will be read- 
ily recognized, though it is not so cas} T to find reme- 
dies which will arrest or modif}' the condition. Still 
bearing in mind the distinction between the unknown 
and the unknowable, we ma}- expect to find remedies 
for even such wrongs as these. 

The wrong of deject is very common, and met with 
in many cases of disease. We recognize it in defective 
or feeble nutrition, parts being small, wanting normal 
solidity, and lacking the usual capacity of our standard 
man. The functional activity is usually the measure 
of the force of organization ; for though the organism 
in such case may for a limited time give a large amount 
of work, it is rapidly exhausted, and requires much 
more than the usual time for recovery. 

"We may learn that such defect is inherited ; that it is 
the result of bad conditions of life ; that it results from 
over-work, or is caused by disease. Whilst we can not 
rectify the present wrong of inheritance, we can pro- 
vide to a certain extent against this in the children of 
the future. But in the other cases the treatment is 



STUDY OF DIAGNOSIS. 259 

quite plain — we rectify the conditions of life and make 
them healthful; we prevent over-work, and remove 
such diseases as influence nutrition. Following this we 
observe the great law of development— Ci as a part or 
function is' rightly used, it gains size and capacity.' 
As we exert the force of organization, we call into 
right action that which the person has, and as it is thus 
normally used, it grows. 

Heat. — The normal temperature of the human body- 
is 98° and a fraction, say 98.4°. To have healthy life 
this must be maintained, with but very slight varia- 
tion ; even the change of one degree producing disease. 
The temperature is accurately determined by the body 
thermometer, applied in the axillae, or under the tongue, 
though it may be recognized less definitely by the 
touch. 

Excess of temperature is met with in fevers, inflam- 
matory diseases, and most diseases accompanied with 
change of structure. As a rule the excess of tempera- 
ture is associated with corresponding frequency of pulse, 
frequent respiration, arrest of excretion, digestion and 
nutrition. In proportion to the excess of temperature 
is the activit}' of causes of disease, of wrongs of the 
blood, and the tendency to destruction in local disease. 
Thus to a certain extent, the excess of temperature 
which we can measure so accurately, becomes a means 
of diagnosing all the wrongs of life. 

As heretofore named, when stud} T ing the changes of 
temperature as an element of disease, the saving fea- 
ture is the diurnal variations in the range. Though 
in protracted disease it may reach the height of 105° 
to 107°, at some period of the day, it falls to 103° tc 



260 STUDY OF DIAGNOSIS. 

102°, at others, and in this fall of temperature the per- 
son has a promise for the maintenance of life. When 
the high temperature is maintained throughout the 
twenty-four hours, the disease is necessarily of short 
duration, either in a fall of temperature and return to 
health, or in death. 

Excess of temperature calls for remedies which 
lessen the processes of combustion, and provide for the 
better removal of heat. The relation between the cir- 
culation and the temperature is very suggestive — as is 
the circulation, so is the temperature — lessen the fre- 
quency of the pulse, and you reduce the temperature. 
Thus the special sedatives are suggested, as among the 
most prominent remedies. Wrongs of sympathetic in- 
nervation (excitement) are associated with excess of 
temperature, and those special remedies, Ehus, Bryonia, 
Gelseminum, Lobelia, etc.. become remedies. Excita- 
tion of the brain and spinal cord are associated with 
excess of temperature, and when noticed, call for rem. 
edies which relieve such excitation. Lesions of the 
blood, especially those of a septic or zymotic character, 
are associated with excess of temperature, and anti- 
zymotic remedies are suggested in these cases. 

The skin is the regulator of the temperature of the 
body. In the continued evaporation from- the surface, 
excess of heat is removed. With a high range of tem- 
perature the function of the skin is impaired, and 
transpiration more or less arrested. Among the ser- 
viceable means to remove the excess of heat, are those 
that put the skin in better condition, favoring transpi- 
ration. Among these means, baths hold a prominent 
place, and should not be neglected. 

Excess of temperature is quite as important a factor 



STUDY OF DIAGNOSIS. 261 

m chronic, as in acute disease, and its recognition is an 
important element in diagnosis. Whatever may be the 
wrong, a range of temperature of 100° and over, means 
a continuation of the disease, and eventually a destruc- 
tion of life. On the contrary, amendment is always 
preceded or associated with a fall of temperature, and 
if this is maintained at the standard of 98°, we may ex- 
pect recovery. Thus in phthisis pulmonalis the range 
of temperature is over 100°, even in the first stage, and 
if maintained at this, recovery is impossible. If it can 
be reduced, and held permanently at or near the nor- 
mal standard, the patient may get well. 

There seem to be three factors in this high range of 
temperature, which require study — the frequency of 
circulation, a wrong in combustion, and a defect in the 
means for regulating the temperature. In some cases 
remedies directed to the wrong of circulation is most 
efficient, as when we employ Veratrum, Digitalis, Cac- 
tus, Lycopus, etc. In others the wrong is of combus- 
tion, either in a deficiency of some element of the 
blood, or in an undue excitation of the nerves govern- 
ing the respiratory function. For the first we think of 
Cod Oil. the ITvpophosphites, Sulphur, and appropriate 
foods. For the second, Arsenic, Phosphorus, Ehus, 
Bryonia, Belladonna, Lobelia, etc. In the third the 
lesion of the skin is prominent, and calls for such 
means as will restore normal functional activity. It 
ma}' be the use of baths — alkaline, acid, stimulant, 
tonic, astringent, inunction, electricity by Faradization, 
or the use of internal remedies that specially influence 
this organ. 

Deficiency in temperature is less frequently met with, 
and not so easily diagnosed. If the thermometer id 



262 STUDY OF DIAGNOSIS. 

axillas or under the tongue, shows 98°. but there is 
coldness of the extremities and surface, showing in 
some places not more than 90°, we have determined 
our case. Or possibly we may find that the normal 
condition of heat. 98°. can be maintained in a state of 
rest, but there is little surplus for motion — we have 
heat as a condition of life, but not as a force. In the 
last .class of cases, the want of power, with exhaustion 
and lowered temperature after exertion, tells the 
story. 

Deficiency of heat may be dependent upon want of 
calorifacient food, upon wrongs of digestion, upon the 
want of some special material in the blood to facilitate 
combustion, upon deficient innervation, upon a wrong 
of the skin permitting heat to be wasted, and upon an 
impairment of the respiratory function. In our ex- 
amination of the sick, the mind at once determines a 
comprehensive plan of examination, and our inquiries 
proceed in this regular order — with regard to food, 
with regard to digestion, with regard to the need of 
special material for the blood, with regard to innerva- 
tion, with regard to the condition of the skin, and with 
regard to the respiratory function. Finding the princi- 
pal wrong, the mind at once turns to the remedies that 
influence the part and function, and selects from them 
the special agent or agents that do that which is needed 
to bring the part or function back to its normal condi- 
tion. 

Unequal distribution of heat is not quite as important 
an element of disease as excess or defect, but in some 
cases plays a not unimportant part. If in long-con 
tinued and severe chronic disease, we have this unequal 
temperature — the trunk being too hot, the extremities 



STUDY OF DIAGNOSIS. 263 

cold — do means will prove curative until the tempera- 
ture is equalized. Physicians may laugh about " equal- 
izing the circulation," •• equalizing the temperature," 
but these inequalities are very common elements of 
disease, and recovery can not take place until they are 
rectified. Hence sometimes means to restore heat to 
the part which is too cold, are among the most impor- 
tant to the cure. Take a protracted case of chronic. 
gastritis or dyspepsia, with continued cold feet, and 
Capsicum in the stockings maj^ be the remedy, or at 
least it will put the patient in the way of being bene- 
fited by others. 

There are some peculiarities in the temperature that 
the thermometer will not recognize. For instance, in 
some cases of zymotic disease, typhoid and typhus 
fever, protracted disease showing " typhoid " sj'tnp- 
toms, the hand placed upon the skin gets a sensation 
of pungrnt heat, veiy like that when it is placed upon a 
surface reddened with mustard, or cantharides. The 
sensation is very distinctive to most persons, and gives 
the idea of sepsis, and unnatural irritation of the vege- 
tative nerve centres. There is nothing more certain 
than this evidence, whenever it is presented, and we 
are at once awake to the danger to life, and the neces- 
sit} T of means to overcome the morbid process going on 
in the blood, and to relieve the over-excited nervous 
system. At once we examine our patient with refer- 
ence to the indications for the special antiseptic — 
Muriatic Acid — the Alkaline Sulphite, Sulphurous Acid, 
Chlorate of Potash, or Baptisia, and with reference to 
the remedies which influence the nerve centres — Aco- 
nite, Yeratrum, Rhus, Gelseminum, etc. 



264 STUDY OF DIAGNOSIS. 

Electricity, like heat, is both a condition of life and a 
force for carrying on the various activities of the body. 
Like heat, it may be in excess or defective, or have an 
unequal distribution. The diagnosis, however, is diffi- 
cult, for we have no instrument to measure its varia- 
tions, as we have in the body thermometer. 

Excess is determined in part by the unnatural state 
of excitation, there being no wrong of the nerve cen- 
tres to account for it. and by a peculiar dry and con- 
stricted condition of the skin. In some rare cases the 
excess is so marked, that sparks may be elicited by 
rubbing the head or the surface in a dark room. When 
the evidence is closely examined we will find that the 
conditions of life have been such as to produce this 
condition. The patient has been a hard brain-worker, 
has lived or worked much in a confined room, heated 
b}' a stove, causing dryness of the atmosphere, and at 
the same time has worn clothing that was a bad con_ 
ductor. Taking, therefore, the symptoms of excitation, 
the constriction of the skin, and the previous history, 
the diagnosis is pretty accurate : and if we add to this 
the evidence of exclusion — no other lesion being found 
that would account for the symptoms — we are certain 
of the lesion. 

The treatment will look to a change in the conditions 
of life. Less work, good ventilation, a moist atmo- 
sphere, and cotton under clothing. Then will come the 
use of appropriate baths to rectify the wrong of the 
skin. And finally, the use of non-stimulating foods, 
and appropriate remedies to lessen nervous excitement. 

Defectm electricity is indicated by opposite symptoms. 
There is a want of energy, and of capacity for con- 
tinued effort, that can not be accounted for by any 



STUDY OF DTAGNOSIS. 265 

lesion of digestion, blood-making or nutrition, or by 
local diseases. The skin is relaxed and atonic, the 
temperature is inclined to be low, and all the processes 
of life are performed with less than usual vigor. These 
symptoms will sometimes be supplemented by a his- 
tory of the conditions of life. A low situation of 
house, dampness of living rooms or shops, trades that 
give a superabundance of moisture in the air, the wear- 
ing of cotton, the use of non-stimulating foods, exces- 
sive drains upon the system in the shape of sweating, 
urination, or seminal secretion, etc. 

Having thus determined the condition of disease, we 
at once think of changing the patient's surroundings. 
He is to have a dry atmosphere, an elevated position if 
possible, air directly influenced by sunshine, sometimes 
sun baths, and that kind of exercise which will call 
into action the respiratory function. This is supple- 
mented by non-conducting clothing of woolen or silk, 
by the use of stimulating inunction, or dry friction 
with the band, or flannel or silk. The selection of 
proper food is sometimes quite important, animal foods 
taking precedence. Some of the restoratives arc use- 
ful, especially the preparations containing Phosphorus, 
sometimes Iron, and occasional^ the Bitter Tonics. 
These may be supplemented by nerve stimulants, Qui- 
nine, Nux Vomica, and agents of like character. 

Cellular Pathology. — During the past twenty-five 
years we have beard much of cellular pathology, and 
it has been proposed to refer us back to these primary 
forms for the history of all disease. According to 
some enthusiasts in the study of cell life, Ave not only 
need to study disease as manifested in cell life, but oui 
23 



266 STUDY OF DIAGNOSIS. 

diagnosis should go back to reach these primary organ- 
isms. Taking the truism, that all wrongs of life mus 
be based upon change of structure, and all manifesta 
tions of life flow from, or are the aggregate of cell life 
the theory becomes very plausible. 

But there is this difficulty: Cells are organisms so 
minute that the}- are beyond the ken of our grosser 
senses. True we can bring them into view with the 
microscope, and to a limited extent we can determine 
changes of shape, but even this is somewhat difficult. 
The best microscopist will fail to detect differences in 
cells, when the expressions of disease may have been 
of the most marked character. 

It is possible to determine degenerations, some de- 
posits, and to a limited extent growths, but many times 
the diagnosis would be post-mortem, rather than at 
such period of life as would give any practical advan- 
tage from it. Even in the case of growths, the micro- 
scope fails to detect the difference between those which 
are benign, and those that are malignant. True there 
are distinctive cancer cells, but then there are malig- 
nant growths without such cells, as there are benign 
growths with those which so closelv resemble them, 
that the best observer may be mistaken. 

The microscope will enable us to recognize some 
changes in the blood-globules, the presence of white 
globules, some changes in secretion and excretion, and 
in the formation of pus, and in so far as it does this, 
it is a valuable aid. Yet in the main, we find it better 
to rel} 7 upon the more common and gross expressions 
of disease, especiall}- as these are suggestive of reme- 
dies. 

If by conceding that life is from cells, and that as are 



STUDY OF DIAGNOSIS. 267 

these cells, so is its expression, we must be referred to 
cells in the study of disease, we may go one step further 
back and say that all life is from molecules, and as are 
the molecules so is the life, and refer 3^011 to the com- 
pound molecules. Failing in this to get beyond the 
human senses, Ave might go a step backward, and en- 
deavor to fix the life of health and the life of disease 
in the ultimate atom, when surely we will be lost. 
Molecular pathology is quite as rational as cellular 
pathology, quite as easy in diagnosis, and furnishing 
just as good a basis for therapeutics. 

Nutrition. — In studying the diagnosis of lesions of 
nutrition, we observe the same order. Having clearly 
before us the factors — food, digestion in mouth, stomach, 
intestine, the process of blood-making, the circulation, 
the condition of the tissues with reference to appropri- 
ation, and even the adverse side, retrograde metamor- 
phosis. Any one or more of these factors may be 
wrong, and we desire to so localize it, that we can 
select our remedy with certainty. It would be most 
absurd, to give u Bitter Tonics and Iron," when the 
wrong was a want of proper food ; quite as absurd to 
em pi oy a stereotyped' tonic when the patient failed to 
properly masticate and insalivate his food, or when the 
lesion was one of the intestinal canal, or a wrong of 
the circulation. We must know the exact location and 
character of the lesion, if we are to prescribe with cer- 
tainty. 

Many wrongs of nutrition are dependent upon a 
want of proper food. In this country where food is 
abundant, it is not usually the want of foods in gross, 
as it is a want of proper selection and preparation, 



268 STUDY OF DIAGNOSIS. 

As the attention is directed to this matter, inquiry soon 
elicits the facts of wrong food, or bad cooking in which 
good food is spoiled, and we are able to set our patient 
right. 

We not un frequently find that food is wrong in kind, 
though it may be good in quality, and well prepared. 
If a man wants animal food, vegetables containing a 
large proportion of starch will not answer well ; if he 
wants calorifacient food, it does not do to feed him upon 
beef-tea. Again we must have regard for the power 
of appropriation by the individual, who may be able to 
digest certain varieties of food, when he can not others. 

Wrongs o i buccal digestion are easily diagnosed in the 
majority of cases by the history given. The patient 
eats rapidty, " bolting his food," which is not properly 
chewed or insalivated. Or he may be an habitual 
tobacco chewer or smoker, and thus by continued abuse 
of the salivary glands have so changed the character 
of this secretion that it can not do its work. 

The treatment of such cases is very plain. The 
patient must be instructed as to the uses of the mouth, 
and the necessity of amending his bad habits. Abun- 
dant time is to be given to each meal, and the food 
thoroughly masticated. If tobacco has been the cause 
of trouble it is to be dispensed with in all forms Fre- 
quently this, without medicine, is sufficient for the cure 
of severe cases. 

The wrongs of stomachic digestion are frequently an- 
nounced by unpleasant sensations which the patient 
refers to the stomach, and points you directly to the 
seat of the trouble. We have the evidences of indi- 
gestion, and a wrong of blood-making and possibly of 
nutrition, in addition to the localization of unpleasant 



STUDY OF DIAGNOSIS. 269 

sensations. Of course the unpleasantness varies in 
different cases, and has the entire range between sen- 
sations of fullness, weight, heaviness, to the most ex- 
quisite pain. 

But having thus localized the lesion, we have only 
made a commencement, for it is necessary to know its 
character, and this hiay be determined in part by the 
sensations of the patient, and examination of the 
tongue and the epigastrium, and by the discharges from 
the stomach. It is possible first to arrange these lesions 
in two classes — irritative and atonic — and even to make 
these classes embrace structural lesions. Probably 
this is the simplest, as it is certainly the best classifica- 
tion, because it points out the remedies required. Rem- 
edies influencing the stomach are readily divided into 
sedative and excitant — the one removing irritation, and 
the other giving stimulation. 

The evidence of irritative lesions is found in uneasi- 
ness or pain of a somewhat acute character, tenderness 
on pressure over the epigastrium, and in many cases 
by injection of the papillae of the tongue, especially of 
the tip and edges, giving the characteristic redness. 
We have every degree in the intensity of these symp- 
toms, from the slight irritation with determination of 
blood, to the well developed inflammation. 

With these evidences of disease, the mind at once 
turns to those remedies which allay irritation — Hydro- 
cyanic Acid, Peach Bark, minute doses of Aconite, 
Ipecac. Rhubarb, Bismuth, Oxide of Zinc, and some of 
the simpler stomachic bitters, as the Hydrastis. If we 
have the general indications for a group of medicines, 
we will find it much easier to select the special one 
which will be most efficient. The reader will notice 



270 STUDY OF DIAGNOSIS. 

that these remedies are alike applicable in all cases 
characterized by irritation and determination of blood, 
even in cases of severe structural disease. 

The evidences of atony are impaired circulation and 
innervation, and want or perversion of function from 
this, is found in sensations of weight and fullness in 
the epigastric region, a sense of oppression referred 
by the patient to the epigastric region. When we ex- 
amine the patient we find that the expression of the 
face is dull, the movements listless and show a want 
of energy. It" we examine the tongue we find it full, 
and expressionless, in some cases pitting where itcomes 
in contact with the teeth. As a rule there is increased 
secretion of mucus, and the bowels are constipated. 

The symptoms above named point the physician to 
that class of remedies which are topical excitants to the 
stomach, and that stimulate a better circulation and 
innervation. Xux Vomica and Strychnine may be 
taken as the type of such stimulants, and are fre- 
quently employed when the impairment is temporary. 
The bitter tonics — stomachic tonics — are the remedies 
usually selected when the impairment is of longer dura- 
tion ; Hydrastis Canadensis. Gentian, Columbo. etc.. 
may be taken as examples of this class. With atony 
there maybe irritability, and in such cases the remedies 
might be Amygdalus Persica. or Matricaria Chamo- 
milla. If the atony is very marked we may employ 
topical stimulants, as White Mustard, -the peppers, or 
combine with the stomachic bitter small portions of 
Podophyllin. 

Atony with increased mucous secretion will be marked 
by the coated tongue, yellowish or gray, especially 
toward the base, full and expressionless features, dull 
eyes, and evidence of oppression. 



STUDY OF DIAGNOSIS. 271 

Iii acute disease it may call for an emetic, may ba 
relieved by a cathartic carefully given, by the use of 
saline diuretics, or by the use of the Alkaline Sul- 
phites. 

Excess of gastric juice will usually be known by its 
eructation, the sense of acidi-ty of stomach, elongated 
papillae of the tongue tipped with white, and mal- 
digestion. 

For it we think of remedies that allay irritation, or 
that remove diseases of which this is sympathetic, as 
of Bismuth, powdered Charcoal, the Alkalies, or the 
Acids, as may be indicated by other symptoms. 

Deficiency of gastric juice is shown by mal-digestion 
and eructations of undigested food for some hours after 
eating. 

It may require stimulants, tonics, acids, alkalies, 
Podophyllin, etc. Eecognizing the deficiency, the 
mind is directed to the cause, and when determined, 
the treatment will be very direct and certain. 

Excess of acid is determined by the eructations, and 
the sense of acidity, but if of the blood as well it will 
be shown in pallor of mucous membranes. 

Whilst the alkalies would seem to be the direct rem- 
edies in the treatment of these cases, they are really 
curative ou\y where there is evidence of this lesion of 
the blood. In other cases the cause must be determined. 
Many times it is a wrong of innervation, and when 
this is removed, the acidity ceases. In some cases, in- 
deed, acids have a more direct influence in effecting a 
cure than the use of alkalies. 

Deficiency of acid may be known by the unpleasant 
fluid eructations, greasy if fatty matter is taken ae 
food. The general defect will be shown in the deep 



272 STUDY OF DIAGNOSIS,** 

redness of mucous membranes, and wherever blood 
comes to the surface. 

This is sometimes the cause of serious functional 
wrong, and until the acid is restored digestion will not 
be well performed. In these cases we usually think of 
"Muriatic Acid as the remedy, though in many Lactic 
Acid will give the best results. 

The symptoms pointing to Pepsin as a remed}' are 
not very direct. Indeed if we should say there was 
an entire absence of S} 7 mptoms it would be a better 
guide to the physician. Given a case in which there 
is indigestion or enfeebled digestion, and there are 
neither evidences of irritation nor atony, acidity nor 
alkalinity, or wrongs of innervation, or disease of 
which this maybe sympathetic, and we would say, give 
Pepsin. 

The wrongs of intestinal digestion require care in diag- 
nosis, as many of the symptoms are obsure and indirect. 
The lesions may be classified as in case of the stomach, 
into irritative and atonic, and the sensations of the 
patient, if they are described, will usually lead to a 
correct conclusion. The pinched expression of face, 
the loss of adipose tissue, giving a shrunken appear- 
ance of body, the contracted tongue, slick, seemingly 
divested of papillae, tell the story of irritation. The 
atony will be indicated by fullness of the abdomen, 
with a sense of atony as the hand is passed over it; the 
full, doughy tongue, inclined to be coated, and the gen- 
eral oppression of the nervous system, give very clear 
intimations of the character of the lesion. 

The irritative condition calls for Aconite, Ipecac, 
Matricaria, Amygdalus, Bismuth, the stomachic bitters? 
Epilobium, etc., and the} T may usually be selected with 



STUDY OF DIAGNOSIS. 273 

considerable certainty: The atony calls for Nux 
Vomica, Chetidonium, Podophyllin, etc. In many of 
these eases the combination of Podophyllin in minute 
doses with one of the simpler bitters, answers an ex- 
cellent purpose. 

As a rule good blood-making follows good digestion 
and having secured the one we are not troubled to 
look after the other, yet sometimes we have the fault 
here and must rectify it. Good blood-making is de- 
pendent upon the conditions already named. There 
must be a normal temperature, a normal circulation, 
normal activity in use, normal waste and normal ex 
cretion. If there is a wrong of either factor we may 
expect some degree of wrong in the making of blood, 
and in nutrition. If at any time we suspect this 
lesion we examine our patient thoroughly with refer- 
ence to these important functions, and finding the 
wrong, whatever it may be, we right it. 

There may be a want of some particular material in 
order to make good blood and good tissue. This has 
been recognized by plrysicians, and is the basis of that 
called restorative medication. We have already seen 
that the plrysician must select the proper food for his 
patients, and that more ma} r depend upon giving his- 
togenetic or ca.lorifacient food, than upon medicine. 

" Restorative medication'* is an indefinite term, as 
used, and. may mean remedies that stimulate an appe- 
tite, increase digestion, giving of proper food, as well 
as the use of those agents which add a needed constitu- 
ent, to the blood. It would be better to restrict the 
term to the use of agents that enter into the formation 
of the blood and the tissues. We may sum these up as 
Iron, Phosphorus, Soda, Lime, Potash, Sulphur, Silica, 



274 STUDY OF DIAGNOSIS. 

Copper, and the bitter principle. These may not be 
all. but if we can get a clear conception of their use, 
the wrongs that follow their defect, and the symptoms 
that point them out, we will do well. 

As Iron is the coloring material of the blood, want 
of color is generally regarded as indicating the use of 
this remedy as a restorative. In some cases the evi- 
dence is sufficiently clear, and when Iron is given the 
effect is direct and positive. If taking the symptoms, 
" want of color from blood," we are careful in our ex- 
amination to exclude those cases where other and pri- 
mary lesions exist, the certainty would be almost abso- 
lute. But there is another indication quite as certain 
as ' ; want of color," when tissues, especially the tongue, 
show' a solid but not deep blue. In these the action 
of Iron is specific. Again we find certain lesions of 
the blood, more noticeably those which give an erythe- 
matous eruption (erysipelas), in which the redness is 
dirty or dulled, in which Iron is specific. 

When the diagnosis is carefully made, the action of 
Iron will give great satisfaction. A recent case of 
uterine disease of long standing with greatly impaired 
nutrition, presented as a prominent feature frequent 
erythematous eruptions of this dirty, though somewhat 
vivid redness, and the cervix uteri and vaginal tissues 
presented the same color. One grain of Iron by 
Hydrogen three times a day. was sufficient to effect a 
cure in a month. In another, where there was im- 
paired nutrition of many years' standing, and no direct 
symptoms but the solid blue tongue, the patient made 
a quick and good recovery on Iron alone. 

The best indication for Phosphorus in its varied 
forms, will probably be found in the want of expression, 



STUDY OF DIAGNOSIS. 275 

both in the face and in movement, an enfeebled respi- 
ration and unequal temperature. The sensations of 
the patient may point to impaired nutrition of the 
nerve centres, or simply to a general failure of life. 
The indications for Phosphorus in the ordinary dose, 
are invariably of atony — impairment of the circulation 
and innervation. In a minute dose it may be used 
where there are evidences of vascular and nervous ex- 
citement with enfeebled tissue — as instanced in low 
grades of inflammation of Jthc lungs. 

Soda is a true restorative in some conditions of dis- 
ease. If deficient in quantity every function of life is 
impaired, and without its restoration recoveiy can not 
take place. In some cases want of Soda is the basic 
lesion, and its administration all that is necessary for a 
cure. In others this deficiency is but one of many 
lesions, and the giving of Soda will be but one of the 
means employed. 

The indication for the use of Soda is clear and un- 
mistakable — want of color in mucous membranes — 
which are usually full. Usually we are guided by the 
tongue, and the expression would be full and pallid — 
Soda. 

The indications for Lime are not so distinct, but yet 
quite definite. We are in the habit of saying that 
Lime is indicated in all idiopathic cases of suppurative 
disease of cellular tissue. The very fact of inflamma- 
tion with a low euplastic or caeoplastic deposit, not the 
result of injury, evidences a peculiar wrong, and for 
this Lime is the remedy. Furuncular disease in all its 
formB, finds a remedy in Lime. In the majority of 
cases, there will be pallor of mucous membranes, though 
in some cases they will be purplish or blue. Lime is 



■"■ 



276 STUDY OV DIAGNOSIS. 

employed in chronic disease of the lungs, with caco 
plastic deposit, determined by a low grade of infiamma 
tion. 

The indications for Potash will be found in pallor of 
mucous membranes, calling for an alkali, and impair- 
ment of muscular power. In most cases a dull, leaden 
hue ol mucous membrane with pallor, will point espe- 
cially to the Salts of Potash. A marked example will 
be found in syphilis, in which this coloration is the in- 
dication for Iodide of Potassium. In some cases a Salt 
of Potash may be needed, even though the deep color- 
ation calls for an acid ; this is sometimes seen in scurvy. 
Here the Soda is excess, Potash is defect, and the 
patient is cured by the administration of Lemon juice 
and vegetables containing Potash in large quantity. 

The best indication for Sulphur as a restorative is a 
change in or want of the pigment of the skin and hair. 
In some cases the dull, dirty color may call for Sulphur, 
in others the blanched surface. Rapid loss of color in 
the hair will sometimes be an indication. Sulphur is 
also indicated by a peculiar blue or leaden color of 
urine and faeces. It would be designated by some, 
"want of color." and so there is a marked lack of the 
natural coloring material of these excretions. If I 
were picking a case to obtain the most marked curative 
action of this drug, I would take the dirty or tawny 
skin with bluish urine. 

The indication for Silica is not very well known. 
I have used it with most advantage when the epithe- 
lium had a lifeless appearance, and there was continued 
tendency to desquamation. Ln some cases these symp- 
toms are followed by severe ulceration of the skin. 
Hahnemann claimed that it was a valuable remed}'- in 



STUDY OF DTAC4NOSIS. 277 

rachitis of children, and named sweating of the head, 
as one of its most prominent indications. 

Copper is not usually regarded as a constituent of 
the body, yet I think it is clearly proven that it is 
present in small quantity. The indication for its use is 
the unpleasant greenish pallor of skin met with in 
some diseases of women, and a veiy similar coloration 
of tongue. In some cases the patient has not lost 
flesh, and nutrition seems to be quite as good as usual, 
but there is a want of energy and power of endurance. 

The Bitter Tonics are in such common use, that it 
would seem hardty necessary to point out the indica- 
tions for their use. But one would find it a little diffi- 
cult to point out clearly the cases in which the bitters 
are direct remedies. One might say "want of appe- 
tite," and as by their topical action they are appetizers, 
he would guess his case off right with the majority. 
Or we may say " impaired digestion," and by their 
topical action they do improve digestion, and we would 
be right in the majority. Or we might say " enfeebled 
nutrition," and as they do improve nutrition, we would 
make a right diagnosis in a great many cases. The 
blood requires a bitter principle, and its want is the 
cause of most serious disease, yet I can not point the 
reader to any better evidence of it than impaired 
appetite, digestion and nutrition. 

Further along, we will see that a right circulation is 
essential to carry the blood, thus well made, to the tis- 
sues where it is to be used. Wrongs of the circulation 
impair the quality of the blood, and the power of the 
tissues to withdraw from it the materials for nutrition. 
Thus in all cases of lesion of nutrition a right circula- 
tion must be maintained. In this connection attention 



278 STUDY OF DIAGNOSIS. 

may also be called to the necessity of having the 
normal temperature of 98°, which, as we have already 
seen, is a condition of healthy life. 

A patient may have good food, good digestion, and 
good blood-making, and yet there will be a failure in 
nutrition. If the tissues are not in a condition to ap- 
propriate the material and weave it into organic forms, 
the patien.t would be better not to take it as food. We 
havealready referred briefly to the properties of form- 
ative cells, and have seen that we have no means of 
determining their condition, except by the physical 
properties of the tissues en m<isse. If they have normal 
hardness, elasticit}*. form, and activity, we have reason 
to conclude that nutrition is good, in so far as the 
power of appropriation is concerned. Conversely we 
may say. if they want hardness, elasticity, form, and 
activity, there is a want of power to organize new 
tissue. Diagnosis is here made by the tactile and 
visual senses, and will be valuable just in proportion 
as these have been trained to use. 

Concluding from these evidences that the tissues 
lack the power of appropriation, what will be the 
remedies 9 In so far as internal remedies are con- 
cerned, we have but few that influence the function of 
the formative cells. To a limited extent, some of the 
bitters may do this. Yet when we subtract their topi- 
cal influence upon the digestive apparatus in increasing 
the appetite and improving digestion, and the slight 
stimulant influence upon the circulation and innerva- 
tion, there is but a small fraction to be accounted for. 

Want of hardness, elasticity and- activity will show 
a want of nutrition, whilst the change in form, want 
of expression — dull and lifeless — mav be taken as evi- 



STUDY OF DIAGNOSIS. 279 

dences of a want of retrograde metamorphosis. We 
have already made reference to the great law of animal 
life — as an organism is used it gains the power of re- 
production and increased use; as it is disused it loses 
this power. But it is well not to forget that over-use 
will impair reproduction, the forces of life being thus 
exhausted. In many cases, after providing for good 
food, good digestion, and good blood-making, a good 
circulation, normal temperature, and good innervation, 
we stimulate the appropriation of material b t y the tis- 
sues b € y well regulated exercise. Or if the patient is 
over-worked, and thus exhausts his powers of repro 
duction, by recommending rest. 

In some cases the patient requires exercise under 
the influence of the will, innervation in this way being 
of as much importance as the activity of tissue. In 
other cases it requires passive movement, with as little 
expenditure of nervous power as is possible. In some 
cases the stimulus of electricity becomes an important 
means, and by its general use normal nutrition of tis- 
sues may be obtained. 

The character of deposits may usually be determined 
by the symptoms indicating the condition of the gen- 
eral health, and by the local appearance of the part 
when near the surface. Bearing in mind that good 
blood will give euplastic deposits, an inferior blood 
cacoplastic deposits, and a very poor blood aplastic 
deposits, we will be in a pretty good position to judge. 
The means of determining this have already been 
pointed oijt. 

As regards the local symptoms we may say that the 
inflammatory process, regular in its course, is the best 
evidence of euplastic deposit. All irregularities, 



280 STUDY OF DIAGNOSIS. 

whether of time, intensity, or of the common symptoms 
-heat, pain, redness or swelling — point to a deposit of 
lower character. So certain is this that the pln'sieian 
will very rarely make a mistake if irregularities cause 
him to employ greater vigilance. If for instance, in 
local disease, there is too much or too little heat, too 
much or too little pain, too much or too little swelling, 
too-much or too little redness, or if the color is changed, 
we are sure the deposit, if there is one, will be low in 
character. So if the disease runs its course too rapidly, 
or progresses too slowly, we conclude that the deposit 
will be of lower grade. So true is this, that Ave look 
with suspicion on all alterations of the inflammatory 
process, and use extreme care in the treatment of such 
cases. 

Degeneration is not easily recognized, and in a major- 
ity of cases it progresses until the destruction is beyond 
remedy. Of course I exclude granular degenerations 
of the kidneys (known by albumen in the urine), and 
degeneration of the liver (known by jaundice), which 
present characteristic functional disturbance. The 
gradually ded'easiug power of continued exertion is an 
important j)oint in the diagnosis. Persons having de- 
generation will find themselves incapable of prolonged 
exertion. There is a want of expression in every part, 
and the soft tissues sit upon the bones like an ill-fitting 
suit of clothes. A want of sharpness and strength in 
the wave of blood as it passes under the finger is an 
additional element. 

In the treatment of degenerations we wish to re- 
establish this " renewal of life." Whilst we want good 
food, good digestion and blood-making, adding an}* 
agents of the class restorative that may be needed, and 



STUDY OF DIAGNOSIS. 281 

an active condition of the formative cells, we also want 
increased retrograde metamorphosis. to remove the old 
and degenerated tissue. In so far as the tissue is de- 
generated it can never be replaced, but it is possible to 
so improve the function of nutrition, that what yet re- 
mains may serve the purpose of the organism. 

The diagnosis of growths belongs to the province of 
surgery, and requires but a brief notice here. They 
are classified as benign and malignant, and to deter- 
mine to which of these two classes a growth belongs is 
the first object. As a general rule we may say a benign 
is a growth from the tissues, whilst a malignant is a 
growth in. A benign growth is distinctly separate 
from the tissues, and though it may be deeply seated it 
obtains room for its enlargement by separating them, 
and occujrving the place of the connective tissue. It 
may interfere with the nutrition and use of tissue by 
pressure and weight, and in rare cases when inflamma- 
tory action is set up may form adhesions to them, other- 
wise it maintains a distinct and separate existence. 
On the contrary, a malignant growth takes possession 
of the tissues of the body, and grows in them, trans- 
ferring the structure into its own lowered forms. It is 
no respecter of tissue, and occupies one quite as readily 
as another, taking possession alike of skin, connective 
cellular tissue, muscle and bones, using the fibrous 
tissue as its skeleton, and the blood-vessels, lymphatics 
and nerves, for its supply, waste and innervation. 

The reader will notice that if in any ease it be pos- 
sible to determine the condition of a growth — from or 
in— the diagnosis is readily made. A growth that does 
not interfere with or take possession of tissue, is of 
necessity benign, whilst a growth* that does appropriate 
24 



^™ 



282 STUDY OF DIAGNOSIS. 

the normal tissues is as surety malignant. In a major- 
ity of cases careful inspection of the part will deter- 
mine this. 

A benign growth is generally of uniform consistence. 
smooth, and of equal elasticity as the hand is passed 
over it. The reader will readily see why this should 
be the case, as it has a single point of origin and 
supply, and consequently a uniform development. But 
in the case of a malignant growth, its consistence and 
elasticity will depend to a considerable extent upon the 
tissues it appropriates, and hence it will be of unequal 
hardness and elasticity — nodulated. 

There is a marked difference in the sensations of the 
part. The benign growth has no nerves, and any sen- 
sation experienced will be from its pressure or drag- 
ging upon adjacent parts. The malignant growth 
appropriates the nerves of the part, and hence inter- 
stitial pain of a peculiar character is usually found in 
these cases. 

A benign growth has no lymphatics, and does not 
influence the blood other than by withdrawing the 
materials for its supply. On the contrary, the malig- 
nant growth appropriates the lymphatics as it does 
other tissue, and furnishes through them a cancerous 
lymph which eventually produces the constitutional 
impairment so generally noticed. 



SECBETION. 

Among the important functions changed by disease 
secretion holds a first place, and in the practice of 
medicine remedies influencing the secretions have held 



STUDY OF DIAGNOSIS. 283 

a first place. Bui very crude ideas of the function of 
secretion have been held,' and of course the medication 
based upon these was equally crude and empirical 
Whilst physiologists have been pretty clear in then 
teaching that (in the main) secretion was purely a vital 
function performed through certain cells, called secre- 
tory, physicians have acted as though they believed it 
a purely physical process, like the osmose that occurs 
through an animal membrane. If secretion is a vital 
process, life is an essential, and the conditions of life 
necessary; if it is a physical process of straining, then 
a dead tissue may secrete as well as a living one. 

There is little use to talk of diagnosis here, unless 
we have first a clear idea of the apparatus of, and the 
conditions for secretion. If we can clearly appreciate 
that in the case of all the secretions — recrementitious 
and excrementitious — there must be a membrane con- 
tinuously giving birth to secreting cells, and that these 
grow to the normal stature of cells, withdraw from 
the current of blood the special material of their secre- 
tion, and then discharge themselves with it in the com- 
mon duct, Ave will have a basis for correct diagnosis 
and therapeutics. 

Taking one step further, we find that function not 
only depends upon life, but upon the normal conditions 
of life. This is true of every part and every function 
of the body. Studying the life of cells, and secreting 
cells bear a very close relationship to formative, we find 
that a certain temperature, circulation and innervation 
are necessary.* Probably the life of the secreting cell 



*These conditions are as necessary to the entire organism as 
to the individual cell, otherwise we would not be benefited "by 



284 STUDY OF DIAGNOSIS. 

is not so much affected by changes of these, as the life 
of the formative cell, but in a certain range it is so de- 
pendent ; whilst the range is greater the effect beyond 
certain points is just the same. 

The cause of lesions of secretion may be general or 
local, and the diagnosis is made by an analysis of gen- 
eral symptoms influencing secretion at large, and 
symptoms pointing to local lesion of the secreting 
organs. When secretion in general is affected, we have 
good reason to think that the lesion is general ; when 
but a single secretion is affected we have good reason 
to believe that the lesion is of the organ furnishing the 
secretion. 

When all the secretions are involved, the cause, as a 
rule, will be found in changes of temperature, circula- 
tion, innervation, digestion, blood-making and waste. 



knowing them. We have constant cognizance of the gross form, 
while the minute structure is beyond our vision only as we bring 
the microscope to bear upon it. Let us now see how they are 
applicable to the body as a whole. 

First. — An original viability is seen to be an imperative condi- 
tion. A want of this gives us hereditary diseases and early 
death. A want of it also gives us an enfeebled life and a want 
of resisting pow T er to the ordinary causes of disease; while a 
strong viability gives great resisting power to disease, and long 
life. This has already had a partial consideration. 

Second. — A proper supply of nutrient material is also an abso- 
lute condition, as man only lives by a constant renewal of his 
body. The material for this renewal being furnished, and the 
cells possessing a normal formative power, life continues in a 
regular manner. 

Third. — The circumstances favorible for normal development 
in man are a normal circulation, innervation, temperature, and 
excretion. — Principles of Medicine. 7_ 



STUDY OF DIAGNOSIS. 285. 

If now secretion is to be restored to its normal condi- 
tion, we want normal temperature, normal circulation, 
innervation and waste, especially the first three. In a 
large majority of cases, secretion is re-established so 
soon as the conditions of life permit, without the. -use. 
of special means to this end. Thus in acute disease, if 
means are employed to rectify the wrongs of circula- 
tion, the temperature and innervation, we find that the 
tendency is to a re establishment of secretion as the 
conditions of health are approached. 

Local lesions of the secretory apparatus are best 
classified as irritative and atonic, as it points out the 
classes from which our remedies are to be drawn. 
When a part is involved there will be in nearly all 
cases such unpleasantness of it as will call the attention 
of patient and physician to the wrong. It may be 
pain, or something less pronounced than pain, but i, 
gives the special part a distinctive character separate 
from the general life. In health the body is a unit, 
and all sensations are pleasurable, in local disease there 
is a feeling of separateness between the part and the 
life, and the severer the disease (as a rule) the more 
distinct this feeling which regards the suffering part as 
distinct from the life — a foreign body, which it would 
be well to get rid of. 

It is true these subjective sensations are not always 
pronounced, and in some cases the suffering is so mani- 
fested that it seems of some other and distant part. 
Yet if the patient's attention is excited, he readily de- 
termines the wrong sensation, and our knowledge of 
nervous distribution and sympathies will soon translate 
the character and situation of pain. 

The reader will already have been impressed with 



286 STUDY OF DIAGNOSIS. 

the character of pain as determining the condition of 
a part as regards excitation and atony. Excluding 
neuralgia, acute sharp pain is the evidence of undue 
excitation and an active condition, whilst dull pain and 
sensations of weight and fullness, indicate atony, with 
impaired circulation and innervation. It may he said 
that this method of diagnosis is too gross and arbi- 
trary, hut I think in the majority of cases it will serve 
as a good basis for the selection of remedies. 

With this method, we should say the absence of local 
symptoms points to general disease, and we carefully 
examine our patient with reference to the conditions 
of normal secretion. Finding the wrong in tempera- 
ture, circulation, or innervation, we select from those 
remedies that influence the particular function, and 
take that one which in its action is opposed to the dis- 
ease, and in its influence brings the functional wrong 
toward the standard of health. Determining a local 
wrong, we at once think of those remedies that espe- 
cially influence the organ or part, and take that one 
which in its action will do that which favors the health}' 
life of the part. Nothing can be simpler than this in 
theory, as nothing, I am sure, will furnish a better 
basis for a successful practice of medicine. 

Secretion is divided into two classes, recrementitious 
and excrementitions. and it is well for the reader to 
have a good knowledge of these distinct from each 
other, learning the uses of each. We want to know 
the simple facts, with regard to the use of saliva, gas- 
tric juice, bile, i^ancreatic fluid, and the small glandulse 
of the intestine in digestion, that we may weigh the 
wrongs which may arise from changes in these secre- 
tions. We want to know the value of mucus as a 



STUDY OF DIAGNOSIS. 287 

lubricant and protector of mucous membranes, and of 
the sebaceous secretions as a lubricant and protector 
of the skin. And we want to know the value of excre- 
tion from the lungs, the kidneys, skin, and bowels, as a 
means of removing worn out and effete material from 
the body. It is direct thought that we want, for when 
the mind is directed to a single object it readily grasps 
it, but when it is made to embrace a multitude of 
objects, they become indefinite and indistinct. 

If. for example, we are called to a case of increased 
secretion of saliva the diagnosis is easily made, for the 
senses can not fail to be impressed by the increased 
amount of fluid in the mouth. But the questions that 
follow are not so easily answered — is it mercurial 
from local disease of the salivary glands? from disease 
of parts contiguous? from diseases of the digestive 
apparatus below? from disease of the brain ? or from a 
lesion of the sympathetic system of nerves? It seems 
difficult at first to make such diagnosis, and yet as the 
mind considers one after the other of these, with such 
light as additional symptoms may throw on it, the 
problem is soon solved, and in its solution we are 
directed to the particular class from which the remedy 
is to be selected, and possibly the special remedy which 
will cure. 

The example given above is one of the most com- 
plex, and we will find the others simpler. If we take 
the secretion of gastric juice we might make a different 
study. First, is the disease general, local, or sympa- 
thetic? If the examination is carefully conducted, the 
absence of evidence of local disease, and of parts with 
which the stomach is in special sjnnpathy, and the evi- 
dences of general lesions which might affect the 



288 STUDY OF DIAGNOSIS. 

stomach, will determine tho first classification. But if 
the local symptoms were pronounced, and there was 
wanting the evidences of general or sympathetic dis- 
ease we would have determined the second classifica- 
tion. Whilst if we had pronounced disease of parts 
with which the stomach sympathizes, as of the uterus 
or brain, but without marked symptoms of local or 
general disease, we would have determined the third 
classification. It may be that we will find two, or pos- 
sibly three of those causes in some cases, but we reach 
our conclusions b} 7 these methods of examination and 
thought. 

If we take the liver as the next example, we will 
find it necessary to employ a different method. The 
first questions we ask are with reference to local disease. 
Has the patient unusual sensations in the right hypo- 
chondrium, of pain, weight, distension, pressure up- 
wards on lungs, toward the mesial line on the stomach ? 
is there tenderness on pressure, sense of fullness when 
the hand is passed over the part, or can the organ be 
felt below the margin of the ribs? Is there expression 
of disease from adjacent parts, as from the bowels, 
stomach, lungs? Is there a wrong in the uses for 
which the bile is secreted? 

It is always well to get rid of old-time errors, and in 
these methods of diagnosis we wish to start with a 
right pl^siology. What is the use of bile? Your 
physiologist will tell .you, possibly, that he does not 
know, but he is sure that it is not, as was formerly 
thought, an excretion, but that it is elaborated to serve 
uses in digestion and blood-making. As 3^011 read on, 
and think of what you are reading, you see the absur- 
dity of the old practice of medicine, which was con- 



STUDY OF DIAGNOSIS. 289 

tinuously looking after the liver and the secretion of 
bile, and talked glibly of liver complaint, liver disease, 
"your liver is affected," and about liver pills, chola- 
gogues, "touching the liver," etc. It requires but 
little study to get rid of this old rubbish, and reach 
the conclusion that the liver does its work very kindly 
and well, and is an organ that aids nutrition, and not 
waste. If, therefore, we find a wrong of intestinal 
digestion, in which the liver is very surely concerned, 
we may look after the condition of this organ. 

The secretion is peculiar in color, and sometimes 
wrongs of the liver may be determined by this. Thug 
faecal matter is to some extent colored with biliverdin, 
and if the color is dark we say, excess of bile — if it is 
light we say deficiency of bile. This method of diag- 
nosis is a little crude, for there are many sources of 
error. Thus Lehman showed that the peculiar green 
stools following the administration of Calomel were 
not due to any action of that drug upon the liver, but 
to the presence of Sulphate of Mercury in the faeces. 
An excess of acid may also produce green stools, as a de- 
ficiency may render them lighter in color. 

The cutaneous pigment will prove a better guide 
than the color of the faeces. The yellowness of jaun- 
dice will be called to mind as an instance, and many 
will recollect brownish spots — liver maculae — that are 
very clear ly traceable to the liver and its associate 
organs. But a change in the pigment less marked than 
this has a very definite meaning. I allude to a tawny 
coloration of the skin, giving it a dull, dirty appear- 
ance. I believe this always points to a wrong of the 
chylopoietic viscera, especially to innervation from the 
25 



290 STUDY OF DIAGNOSIS. 

solar plexus, and indicates the class of remedies that 
have been regarded as " liver medicines."^ 

But the really important point to determine in these 
cases is, the condition of the organ with regard to ex- 
cess or defect, in its circulation and innervation — is 
there excitation or atony? . The symptoms are usually 
distinct so far as this is concerned, and the remedies 
will be clearly pointed out. And yet there is nothing 
in which mistakes are so frequently made. Take, for in- 
stance, a case of jaundice, and the teaching of the books, 
is to give hepatic stimulants — Podophyllin, Leptandrin, 
Blue Pill, Calomel, etc., without reference to the condi- 
tion of the liver. But in one-half the cases, there are 
evidences of excitation in pain, tenderness on pressure, 
and accelerated circulation, increased temperature, dry 
skin and scantj' urine. Surely hepatic stimulants are 
not remedies here, and the} T usually do much harm in- 
stead of good. In such case the patient requires the 
special sedatives, Grelseminum, Acetate of Potash, the 
bath, and possibly the cold-pack or fomentations to the 
right hypochondrium. In the opposite class of cases, 
with sensations of weight, fullness, oppression, unequal 
temperature, etc., such remedies as will stimulate the 
liver and associate organs will prove remedies. 

Again we wish to know in this connection that the 
bile pigment when once deposited in the cutaneous 
tissues is never removed by way of the liver, but is 
always excreted in principal part by the kidneys. In 
so far then as getting rid of the unpleasant coloration 
of skin in jaundice is concerned, we might just as well 
give a remedy to act upon the salivary glands as the 
liver. There are scores of these olden-time errors in 



STUDY OF DIAGNOSIS. 291 

practice that can only be gotten rid of by a carefu' 
study of ph t ysiology. 

The pancreas does a most important work in secretion, 
one which the physiologist clearly understands, and yet 
we hear nothing about "pancreatic complaint," "pan- 
creatic disease," or " touching the pancreas." Indeed 
there are no pancreatic remedies in our Materia Medica. 
Why is this ? There is nothing like getting these sub- 
jects fairly in view, that we may think of them. Leh- 
man remarks — " The function of the pancreatic fluid in 
digestion, may be two-fold, according to the above men- 
tioned properties, namely : to change starch into sugar, 
and to decompose the fats, so as to render them absorb- 
able. That it actiiall} T performs the former in diges- 
tion, has been placed beyond doubt by numerous ex- 
periments. The pancreatic fluid possesses this property 
in a much higher degree than the saliva; it is opera- 
tive at even a low temperature ; neither bile, nor gas- 
tric juice, nor free acids, interfere with the function of 
the fluid." 

What then would be symptoms of disease of the pan- 
creatic secretion? Most surely they would be func- 
tional, and we would find them in imperfect digestion 
of calorifacient foods, a deficient supply of burning 
material, and a more or less rapid consumption of the 
fat stowed in the body. We would naturally expect to 
find unchanged starch and fat globules in the fasces, 
and examination shows that this is the case. Just so 
soon as we begin to reason rightly, we reach definite 
results. 

But if we have no " pancreatic medicines," how will 
we rectify these wrongs, after we have found them? 
This is also eas}^ enough. There are in almost all casee 



292 STUDY OF DIAGNOSIS. 

certain general lesions of the circulation, temperature, 
innervation, excretion, etc., easily recognized, and 
which must be relieved in all cases preparatory to a 
successful local treatment. As local remedies we may 
think of Yeratrum, Cactus, Chelidonium, Oxide of 
Zinc, Nux Vomica, Podophyllum, Iodine in minute 
doses, Panax, etc. They all act " there or thereabouts," 
and we can choose from the list those that act in the 
right direction. 

To the doctor in ordinary, the intestinal canal is a 
place to put pills, powders and potions, for purgation. 
Bowels were made to be moved, and it is the doctor's 
business to move them, and sometimes, it seems, it is 
almost his whole business. He never thinks that the 
intestinal canal is a digestive apparatus, and if he has 
ever learned this in his physiology he has forgotten it. 
And yet this function of the intestinal canal is really 
the most important element in digestion. 

In addition to the bile and pancreatic fluid, we have 
an intestinal fluid secreted by the " bottle- shaped " 
glands of the alimentary canal. With regard to this 
Lehman remarks — '" The intestinal fluid serves, as re- 
gards its function, as a complement to the digestive 
fluids, the gastric and pancreatic fluids, which become 
inoperative toward the middle of the small intestine ; 
it possesses not onlj-, as the latter of these does, the 
power of rapidly changing starch into grape sugar, 
but also of dissolving and rendering absorbable flesh 
and other protein bodies. In tied knuckles of intes- 
tine, into which starch or paste has been introduced, 
all the starch is transformed into sugar at the end of 
three hours, and in a great measure absorbed. Pieces 
of meat or coagulated albumen disappear from such 
knuckles after six to fourteen hours." 



STUDY OF DIAGNOSIS. 203 

This is good reading, my friend of many cathartics, 
and it is Avell to give it a prayerful consideration. Here 
is a fluid that will do the entire work of digestion, and 
here is an apparatus that really does do a considerable 
part of it. When you have occasion to use the old- 
fashioned harsh remedies, think twice, and possibly 
you may see that the wrong done to this important 
function may outweigh, many times, the good that 
comes from counter-irritation. 

The remedies named above, for wrongs of the pan- 
creatic secretion, may be employed here, with some 
additional ones. What we want to know, as a basis for 
a rational prescription is — do we want sedation or 
stimulation — do we want it of the circulation, or the 
innervation, though these are usually associated. It is 
hardly worth while to point out now the special indi- 
cations for Amygdalus, Bismuth, Nux, Chelidonium 
Aconite, Ipecac, Nitric Acid, Podophyllin, etc., for their 
uses will have been learned elsewhere. 

Mucus is secreted to lubricate and protect mucous 
surfaces, and in normal amount it favors the perform- 
ance of function. Wrongs of the secretion are usually 
easily determined. If of the outlets of the body, the 
condition may be seen and felt. Thus it is easy to re- 
cognize increased secretion from the nose, throat, and 
genito-urinary passages, from the abundant discharge. 
Increased secretion from the bronchial mucous mem- 
branes is known by its discharge, and also by the blow- 
ing and rattling sounds heard during cough and on 
auscultation. Increased secretion of mucus in the 
stomach is usually shown by the heavily loaded tongue 
at its base. Whilst increased secretion of mucus in the 
intestinal canal will be shown by the uniformly dirty 



294 STUDY OF DIAGNOSIS, 

tongue, and b}^ the tumid abdomen Scanty secretion 
gives rise to irritation, and this is one of the prominent 
signs, and taken together with the absence of discharge 
is very good evidence. 

With a wrong of mucous secretion we ask the ques- 
tions — what are the general wrongs, operative in this 
case? what is the condition of the mucous membrane, 
as regards its circulation and innervation? It is a 
rule in practice, to rectify any general lesions, prepara- 
tory to the cure of local disease, and many times with 
this the local disease will disappear. Thus in a given 
case of acute disease, we have a frequent pulse, high 
temperature, and excited innervation, with dry mucous 
membranes; the use of the appropriate general reme- 
dies will establish secretion. And on the contrary, if 
secretion is too free, the use of appropriate general 
remedies will lessen it. 

When we think of local remedies we want to group, 
a, those which act upon mucous membranes; b, those 
that act upon the special 6rgan, part, or function in- 
volved. Having the classes of remedies before us, we 
now select a stimulant, sedative, or one which by its 
action tends to change the character of the secretion 
or function. It is not difficult to select a local remedy 
if we know exactly what needs be done, and we have 
a clear knowledge of the value of remedies. 

A change in the sebaceous secretion frequently gives 
rise to cutaneous disease. If our attention is directed 
to the function of this secretion, as a lubricant of the 
skin, its lesions Avill readily be detected. The treat- 
ment here will have reference to the condition of exci- 
tation or atony of the circulation and innervation, and 
to changes in the nutrition of the organ. Sedatives in 



STUDY OF DIAGNOSIS. 295 

the one ease, stimulants and tonics in another, and 
remedies that alter morbid action in others, will be 
selected to meet the different cases. 

A wrong in the secretion of tears, or the meibomian 
secretion, may occasion serious trouble with the eye. 
Profuse lachrymal secretion is sometimes a source of 
irritation, always a source of feebleness to the tissues. 
Scanty secretion on the contrary, by leaving the eye 
dry, and without the protection given by this fluid, is 
a cause of irritation. The secretion of the meibomian 
glands Serve an important purpose, and when in excess 
or defect, the function of the eye is impaired, and un- 
pleasant disease may be grown. 

Just so soon as the mind is directed to the parts 
which may be diseased, it is pretty certain by direct 
symptoms or by exclusion, to determine the exact loca 
tion and kind of disease. Then knowing the action of 
remedies, local and general, these may be selected with 
reasonable certainty. 

A wrong in the secretion of cerumen is a very fre- 
quent cause of partial deafness, and many aural un- 
pleasantnesses. It is surely well to know this, and by 
a careful examination determine the character of the 
disease — whether in excess, defect or perversion — and 
also the condition of the secreting structures as it re- 
gards increased excitation or atony. With such knowl- 
edge as may be readily obtained by any one, the treat- 
ment of these diseases becomes successful. 

The principal object in the consideration of these 
secretions is to call attention to the necessity of con- 
stantly keeping our physiological knowledge well in 
hand, and directing attention first to the use, that 
we may be able to understand the disease. If at any 



296 STUDY OP DIAGNOSIS. 

time we forget this, and take the ordinary writers on 
patholog} 7 and therapeutics as authority, we are quite 
sure to go astray. 

The excrementitious secretions are four in number — the 
lungs, the skin, the kidneys and the bowels — and these 
remove the waste of the bod) 7 . The due performance 
of the function of excretion is essential to health, and 
in disease we invariably find a lesion of one or more. 
If the excretions are in excess, debility is the result, 
and becomes a prominent symptom. If they are in 
defect, materials which should be removed, are re- 
tained within the body; the result being irritation or 
oppression, according to the character of the material, 
and the amount retained. 

Excretion by the lungs is but little studied, and yet 
this is one of the most important of the excretions, 
being to the extent of 517 grains of carbonic acid per 
hour. In a rough estimate the value of these excretions 
may be written — lungs eight, kidneys two, skin and 
bowels each one. True it is carbon which is thus ex- 
creted by the lungs, (this being regarded in the olden- 
time as the special province of the liver), but a simple 
experiment in closing the mouth and nose of an animal 
will show that it will kill in a very few moments. 

Excretion by the lungs may be in excess, and this 
will be seen by tbe vivid redness of the blood where it 
reaches the surface, by the frequent full respirations, 
an exalted circulation, an excited nervous system, a 
high range of temperature, and rapid waste of tissues. 
We find these evidences of excess both in acute and 
chronic disease, and it must be evident to the reader 
that means to check it will be of value in both cases. 

Such a remedy as Yeratrum, and to a less extent 



STUDY OF DIAGNOSIS. 297 

Lycopus, Cactus, Sticta^ must prove of great value in 
such cases, associated with such local and topical ap- 
plications as relieve irritation and give rest. The 
reader will see very clearly that in the early stage of 
pneumonia with such symptoms, Veratrum and a mush- 
jacket may prove speedily curative, and that in some 
cases of phthisis. Veratrum becomes a prominent 
remedy. 

Defect in excretion from the lungs will be known by 
the darker color of the blood where it comes to the 
surface, the evident defect in the movements of the 
chest, fullness of superficial veins, and the oppression 
of all the functions from retention of carbonic acid gas. 

At once our attention is directed to such remedies as 
prove excitant to this function, as JNTux, if there is de- 
ficient spinal innervation, Phosphorus, Arsenic, Lobelia, 
Bryonia, Drosera, Apocynum, etc. If by these means, 
excretion of carbonic acid can be increased, the various 
functions of life are relieved from oppression. 

Even if this, knowledge did not point us to special 
remedies, it would be valuable as suggesting a proper 
hygiene. The patient suffering from excess wants 
quiet and rest, a moist atmosphere, and one not stimu- 
lant. The patient suffering from defect requires such 
exertion as will call into action the respiratory appa- 
ratus, a dry atmosphere, and one which is stimulating. 
Proper direction in these regards maybe the one thing 
necessary to recovery, and we can only give such ad- 
vice when we thoroughly understand our case. 

The attentio.ii of physicians has been specially 
directed to the skin, kidneys and the bowels, as the 
apparatus of excretion, the importance of this function 
to health, and as a cause of disease. Indeed they have 



298 STUDY OF DIAGNOSIS. 

received too much attention (such as is) for three- 
fourths of the Materia Medica has for its object an ac- 
tion on these emunctories. If we should take away 
from the regular physician his cathartics, diaphoretics 
and diuretics, he would be poor (for harm) indeed. 
Whilst- I do not wish to depreciate these functions, 
either in health or disease, I think a much more care- 
ful study should be made of them, and that their thera- 
peutics should be improved. 

This fact should be especially learned — that in a 
large majority of cases wrongs of excretion are depen- 
dent upon changes in general conditions of life — the 
circulation, temperature and innervation — and that 
when these are corrected, the excretions resume their 
normal condition. Even when the function is not re- 
stored, very simple means are usualtyall that is required. 

Excess in secretion from the skin is readily deter- 
mined by its moisture to the touch, dampness of the 
clothing, as well as by the patient's sensations. The 
questions that follow are — is it from excitation, or is it 
a result of debility? It rarely results from excitation 
in disease, though once in a while from increased circu- 
lation to the ski fi, as in some cases of rheumatism, and 
in the so-called sweating fever, and some other anoma- 
lous cases, this will be found to be the case. Here the 
diagnosis is quite clear — the skin has an active circula- 
tion, is deepened in color, and the temperature is in- 
creased. The increased perspiration of debility is not 
secretion, but an exudation of water, washing away a 
small quantity of albuminoid materials. The condi- 
tion is determined by the evident relaxation and loss 
of tone to the touch, the pallor, and usually the want 
of sensitiveness. 



STUDY OF DIAGNOSIS. 299 

Evidently the treatment will be different in the two 
eases. The one of excitation requires the special seda- 
tives, Aconite, Yeratrum, Grelseminum, or special reme- 
dies influencing the sympathetic nervous system as the 
Rhus. Lycopus, etc. We want to relieve the undue ex- 
citation of the skin, and this accomplished the sweating 
ceases. In the other case an opposite treatment is re- 
quired. Here we select such remedies as stimulate the 
the skin — stimulant diaphoretics — Serpentaria, Senega, 
Erigeron, Erecthites, Polygonum, etc. Or stimulants 
to the circulation and innervation, as Belladonna, 
Lobelia, Ipecac, Bryonia, etc. Local means will vary 
just as much, in the one case being sedative, in the 
other stimulant. 

Defect in secretion may usually be known by exam- 
ining the skin, which in one class of cases gives the 
hand a sense of dryness and constriction, and in another 
dryness with want of elasticity and life. The symp- 
toms produced hy retention of this excretion, are first 
of oppression, terminating in chill, and second of exci- 
tation, giving the phenomena of fever. As will be seen, 
the general symptoms are somewhat indefinite, for both 
the oppression and stimulation may be the result of 
other causes. It is well to give due weight to this 
lesion, though we may not rest our entire practice 
upon it. 

If the defect in secretion is due to an increased cir- 
culation and temperature, means to rectify these wrongs 
will stand first. In a majority of cases of fever and in- 
flammation, a right use of the special sedatives and 
proper baths will place the skin in such condition that 
it will resume its function ; or that it can be called into 
action by very simple remedies. In other cases, where 



300 STUDY OF DIAGNOSIS. 

the wrong of circulation, temperature and innervation 
is based upon other special lesions, the use of the special 
remedy for this, is followed by a return of normal cir- 
culation, temperature and secretion. A marked ex 
ample of tbis will have been seen in the administration 
of Tincture of Muriate of Iron in some cases of erysip- 
elas, as well as in the use of Ehus. when specially 
indicated. 

If the defect is due to a want of excitation in the 
cutaneous nerves and circulation, remedies are employed 
which exert a stimulant influence upon the skin. Many 
diaphoretics owe their power to influence this secretion 
to their stimulant influence, and of course they can be 
beneficial only when a correct diagnosis is made, and 
they are rightly used. 

Perversions of this secretion are not uncommon, but 
owing to our imperfect means of diagnosis are rarely 
recognized. " This fluid, (sweat), as it collects in drops 
on the skin of one perspiring, is colorless, tastes salty, 
has a peculiar odor, is poor in solid constituents, and, 
wben recent, always reddens litmus." Yet we find in 
disease that it has color, sometimes to the extent of 
coloring the clothing, varying in shade and intensity ; 
has a variety of tastes, sweet, sour, acrid ; is rich in 
albuminoid elements ; and is sometimes neutral to test 
paper, and in other cases will change red litmus blue. 
Evidently here is a field that will repay investigation. 
Authorities upon skin diseases have recognized the fact, 
that perversion of the secretion may be a cause of 
some of these, and may perpetuate the most intract- 
able. 

In so far as we know now treatment will be directed 
to the physical condition of this organ, as shown bj 



STUDY OF DIAGNOSIS. 301 

examination, and to lesions of the blood. The last are 
sometimes very important, for so long* as there is in 
this fluid morbid material that is excreted by the skin, 
so long will the skin suffer. 

Before leaving this subject, I wish to call the reader's 
attention to the character of normal cutaneous secre- 
tion, and to the fact, that in so far as it is a secretion it 
is effected by secreting cells. In its normal state, the 
skin has a uniform temperature slightly below that of 
the blood, gives to the hand a pleasant sensation of 
softness and elasticity, is not damp and moist, indeed 
rarely shows moisture upon the surface except on in- 
crease of temperature and exertion. As this is the 
condition in which it does the best work, it is the con- 
dition we wish to obtain in disease. Many act as if 
they supposed secretion from the skin necessitated the 
pouring out of an increased quantity of fluids upon the 
surface, as from the old class of sudorifics. Yet in 
practice we find that the soft and but slightly moist 
skin is the best evidence of secretion. 

We have already studied the urine as an index to 
disease and a means of diagnosis, and it will only be 
necessary here to notice a few of the more salient fea- 
tures connected with this study. Whilst the physician 
is aware that the secretion of urine is indispensable to 
life, in that it removes the largest portion of the nitro- 
genized waste, he finds the common means of diag- 
nosis so defective, that he takes it for granted that the 
kidneys are doing their work right, because in a very 
large percentage of cases, they do their work right. 
As a matter of form he will ask — "how is your urine? " 
and in the olden time he might examine a mixture of 
urine and faeces in the chamber utensil. If the patient 



302 STUDY OF DIAGNOSIS. 

complained of scanty urine, it might mean something, 
if there was uneasiness in voiding it, there was prob- 
ably something wrong, and if there was arrest, very 
surely something must be done. But just what that 
something should be, was not so definite, only that it 
must be drawn from the class diuretics, and was usually 
the favorite prescription. 

In this study it would be well for us first, to see why 
in any case the urine should receive a special examina- 
tion, and then how this examination should be con- 
ducted. We rake it for granted that in ordinary prac- 
tice examinations of urine will not be made. 

In acute disease retention of the elements of the 
urine are so clearly shown by the nervous sj^stem, that 
there can hardly be a failure to have our attention 
directed to them The first influence is that of excita- 
tion — the patient becomes restless and irritable and suf- 
fers more than the condition of disease will account for. 
The second influence is of oppression — the patient be- 
comes dull and lethargic, and finally sinks into coma. 
Of course we may have cerebral excitation and coma, 
without any wrong of the urinary secretion, but we 
never fail in these cases to make diligent inquiry, and 
satisfy ourselves as to the source of the nervous 
lesions. 

Now scanty urine has a definite meaning, as has un- 
pleasant sensations in its passage, or a failure to pass 
it, or going further, we ma}' make a critical examina- 
tion of it. as heretofore named. I do not wish to be 
understood as saying that inquiries with regard to the 
urine need not be made unless there is nervous dis- 
turbance, for there can be no harm in thorough exami- 
nations in all directions — but I desire to impress it 



STUDY OF DIAGNOSIS. 303 

upon the mind of the reader that these are the cases 
where sneh examination is imperative. 

But finding a failure upon the part of the kidneys to 
do their work, we are not yet ready to say — give " diu- 
retics-" We want to know the condition of the kid- 
neys as regards their circulation and innervation. Such 
arrest may result from irritation and determination of 
blood, and any excitant may so increase this as to en- 
tirel}' suppress the secretion and cause death. Or it 
may result, from capillary congestion, which the ordi- 
nary diuretics would increase, and thus death might 
result from the use of remedies which in ordinary cases 
would increase secretion. 

The condition of the kidneys may be determined in 
part from the patient's sensations, and in part from a 
personal examination. In irritation with determina- 
tion of blood (active condition) the patient will have a 
sense of constriction in the loins with tensive or draw- 
ing pain, sometimes seeming to be in the spine. Some- 
times the sense of irritation extends to the bladder, the 
urethra, the testes, and even to the rectum. In irrita- 
tion the patient is restless, quick in his movements, the 
eyes are bright, the tissues around them seemingly con- 
tracted, the tongue small and pointed, and the pulse 
small, wiry, or vibratile. In congestion the patient 
complains of a sense of fullness and weight in the loins, 
and sometimes the same sense of fullness and weight 
in the pelvis. The patient is dull and apathetic, the 
eye dull, the face expressionless, the tongue somewhat 
full, and the pulse lacks sharpness in the wave — op- 
pressed. 

Such diagnosis is of especial value, because it en- 
ables the practitioner to select his remedies with cer- 



304 STUDY OF DIAGNOSIS. 

tainty. If we have the condition of irritation, we give 
Gelseminum, with or without the sedatives, as may be 
indicated. If there is the condition of congestion we 
give Belladonna, Ergot, or Solatium, with or without 
Aconite as the sedative. Diuretics are not given until 
there is marked relief, and secretion has become more 
free; indeed, sometimes they will not be required at all. 
When we do give them, they are selected with refer- 
ence to the condition of the kidneys — sedative diure- 
tics for the condition of irritation, stimulant diuretics 
for that of congestion. 

Excess in this secretion is not of frequent occurrence, 
and is usually recognized without trouble. The large 
amount of urine in diabetes, insipidus and mellitus, at- 
tracts the patient's attention, and is evidence to the 
physician of the nature of the wrong. But there are 
a few other cases in which the excess is not marked in 
this way— the patient passing but the usual amount of 
urine, or possibly it is less in volume than usual. It is 
only when tested with the urinometer that it is found 
continuously of high specific gravity, and that the 
solids are increased from one-tenth to possibly one- 
fourth more, and still it does not contain sugar or albu- 
men. Such excess will be marked by loss of flesh and 
strength, and by feelings of weight and dragging in 
loins or pelvis. 

The wrong may be wholly due to a lesion of the 
kidneys, or principally to an excess in retrograde me- 
tamorphosis. This of course must be determined to 
give us a rational treatment. 

Attention is rarely called to lesions of perversion hj 
the common examinations of the urine. Of course 
there arc exceptional cases, as the excess of urine in 



STUDY OF DIAGNOSIS. 305 

diabetus mellitus, and urinary irritation in some cases 
of deposit, in which the direct symptoms are sufficient 
to excite attention. In the majority, the diagnosis is 
made by exclusion There is an impairment of the 
health; object — to locate and determine the character 
of the lesion. And thus we give the patient a thor- 
ough examination, with reference to the more import- 
ant functions and organs. Is it of the circulation, 
digestion, respiration, innervation, nutrition, secretion 
of skin, bowels, kidneys f Thus excluding one after 
the other, as we find them free from disease, we at last 
reach the affected part. Even now we do not know 
the character of the lesion, and proceed by the same 
method to determine it Is there sugar in the urine, 
albumen, blood, the phosphates, or some of the rarer 
morbid materials? The general symptoms may point 
us to the special examination, or we may be obliged to 
make test after test, until Ave determine what the real 
trouble is. 

But having learned the character of the perversion, 
we are not yet ready for treatment. It will not do to 
sa}^, here is a remedj^ for all. cases of diabetus mellitus, 
albumien blood, deposit of the triple phosphates. 
The examination must go a step further — to what extent 
is it a lesion of the kidneys, or of some other part, the 
blood, nervous system, or the associate secretions from 
lungs, skin and bowels? and still a step further, we want 
to know the physical condition of the kidnej^s, and the 
special character of any other wrong. 

The reader ma}^ say these methods are very com- 
plex, and it will be difficult for one to follow them 
out (?) I admit it, and whenever possible, should rather 
prescribe from a single characteristic symptom, but 
26 



306 STUDY OF DIAGNOSIS. 

there arc cases that require just such thorough analysis 
to give succeesful treatment. 

When we study excretion from the bowels, we want 
first to correct our physiological ideas of the value of 
the secretion. Physicians have made a hobby of the 
bowels and have ridden millions of them to untimely 
graves. We want to know if bowels were made to be 
continuously ph} r sicked? and whether good or harm is 
most likely to result from the common use of purga- 
tives? If we consult Lehman again, (a most excellent 
authorit}^), we find that — "The contents of the intes- 
tines, even after the use of tolerably simple articles of 
diet, consist of a mixture of undigested, indigestible, 
and already changed or decomposed substances, with 
which are mingled constituents, partly undecomposed, 
partly already metamorphosed, of the digestive fluids." 
But of a real secretion eliminated by the glandulae of 
the intestine the faeces contain but a small proportion — 
probably less than the excretion from the skin. 

Excess is usually associated with frequent fluid evac- 
uations — diarrhoea — yet we must not take it for granted 
that in all cases of diarrhoea there is excess. Excessive 
discharges of faeces produce debilit}^, first by the re- 
moval of some portions of the food, and secondly by 
withdrawing some of the albuminoid materials of the 
blood. 

Constipation is not to be regarded as positive' evi- 
dence of defect in secretion from the bowels, as it is 
possible, and not uncommon, for constipation to exist 
for days, and yet excretion goes on into the bowels as 
before. But even constipation may be a cause of dis- 
ease, either from irritation produced by the debris of 
digestion, or by the decomposition of some of the 



STUDY OF DIAGNOSIS. 307 

material, or by the generation of offensive gases, or the 
absorption of some of the decomposed matters. Evi- 
dences of irritation, or of oppression, when they can 
oe referred directly to inaction of the bowels, may be 
regarded as an indication for the simpler cathartics. 
The more harsh remedies of this class have usually 
been used for their derivative effect, and the saline 
hydragogne cathartics to deplete the blood-vessels of 
fluid. 

Small doses of some of the cathartics, as Podophyl- 
lum, Apocynum, etc., do increase the secernent function 
of the intestine, and at the same time improve its func- 
tion of digestion. The dose is less than that required 
for catharsis, and the indications are sensations of full- 
ness, weight and atony. 

Perversions of the secretions of the bowels and acces- 
sory glands are recognized principally by changes in 
color and in odor, but these are not as certain as would 
be thought at first sight. The reasons are clear — there 
is so much and varied coloring material taken with the 
ingesta, and the odor naturally intense and foul is so 
readily changed by decomposition of faecal material. 
Still it is well to make the faeces yield all the informa- 
tion possible. 

A few examples may be given in illustration. The 
vivid green discharges of childhood, acrid and irritat- 
ing, give information of excess of acid, and suggest the 
use of alkalies. The extreme yellow (chrome) of in- 
fantile discharges, evidence an insufficient digestion of 
the food, both of albuminoid material and fat, and sug- 
gest more care in diet, and the use of remedies that give 
tone to the digestive apparatus. The clay-colored evac- 
uations of disease tell of want of secretion from all 



308 STUDY OF DIAGNOSIS 

the intestinal glands (liver included), of impaired 
power of digestion, and suggest the use of stimulants to 
the upper intestinal canal and associate viscera. The 
yellow rye-mush faeces of typhoid fever is characteristic, 
and calls our attention to commencing disease of Pej^er's 
glands. The deep brown or black faeces, with greenish 
tinge, sometimes yeasty, is one of the most marked in- 
dications of the typhoid condition, and calls attention 
to the necessity of antiseptics. The color and physical 
properties of mucus, pus and blood, are readily recog- 
nized, and either by their quantity, condition, or some 
local s3rm.pt0.ms, their source may be readily detected. 



THE BLOOD. 

The study of the blood is one of much interest to 
the physician, for in changes of its structure and circu- 
lation we find a principal element in many diseases. 
The old Hebrew poet well remarked that — " the blood 
is the life of the man," at least we find by experience 
that wrongs of the blood are manifested b}^ impairment 
of the life. We study both the lesions of the blood 
and the lesions of its circulation, and it is well to keep 
them separate in the mind. 

Excess in the amount of blood is of very rare occur- 
rence as a cause of disease, and yet occasionally Ave 
meet with cases in which, from local disease, the high 
stimulus of a. large amount of rich blood is injurious. 
We find such cases in local disease of the kidneys, the 
lungs, the heart, the brain, in which these organs, en- 
feebled by disease, can not bear the strain of such vig- 
orous life. This has been named sthenic plethora 



STUDY OF DIAGNOSIS. 309 

There is another condition in which a large amount of 
blood is continuously made, but owing to exhaustion of 
the circulatory apparatus and nervous system by ex- 
cesses, its circulation is sluggish* 

Excess of blood is readily recognized by the fullness 
of the blood vessels, especially of the capillary system 
of the surface, which shows the deep tint of abundant 
red globules, by the full firm tissues, and the vigorous 
performance of function. Asthenic plethora will be 
recognized by fullness of blood vessels, oppression in 
the stroke of the pulse, and a turgid venous circulation, 
giving the surface the peculiar color of venous blood. 
The color is so characteristic, that when associated with 
the full animalized tissues, and the full blood vessels, 
there can be no mistake in the diagnosis. 

When high stimulus is likely to be a source of danger, 
we take measures to lessen the quantity of the blood. 
The safest means is to diminish the supply of food to a 
minimum, and select such vegetables and fruits as yield 
small proportions of nitrogen ized material. In some 
cases the saline purgatives and diuretics may be em- 
ployed to a limited extent with advantage, which, with 
well regulated exercise, will remove the source of 
danger. Many a man has lost his life because his 
digestive and blood-making organs were so much 
better than the remainder of his body, that they have 
furnished the material for a too active life. In asthenic 
plethora the important remedy is right living. Cut off 
the supply of stimulant drinks and food, establish good 
excretion, and have the patient take such exercise as 
will promote a more rapid combustion and waste of 
effete material, and in a few months the patient will be 
on safe ground. 



310 STUDY OF DIAGNOSIS. 

Defect in the quantity of the blood — anaemia — -is 
readily recognized by the want of color of surface, and 
the loss of that hardness and elasticity of tissue that 
we call tunc, and a loss of size and functional activity 
of the soft structures of the body. '" : As the life of the 
man is his blood," we have a loss of life in proportion 
to the condition of anaemia. 

But we may have gone so far in our diagnosis as to 
determine absolutely that there is a want of blood, and 
yet not be ready to make a prescription. It will not 
do to say, give Iron, or give " Bitter Tonics and Iron." 
We want to know why a sufficient amount of blood is 
not made, or why, if made, it is not applied to its proper 
use — nutrition. In one case it will be a Avant of proper 
food, or of some special element of the blood, in another 
a want of buccal, gastric or intestinal digestion, in 
another a wrong in the blood-making organs, in an- 
other a lesion of the circulation, in another a lesion of 
innervation, in another a lesion of retrograde meta- 
morjmosis or excretion. Is it too much to ask that 
each of these receive due consideration, and that our 
prescription should be directed to the special fault? 
It requires a little time to pass all this in review, but 
the mind w r orks very rapidly, and taught to work 
right, it will do all of this automatically. 

Of course the treatment of anasmia must vary in 
different cases, as the cause of it varies so much. In 
one case good food, well prepared, is all sufficient ; in 
another some special element of blood needs to be 
added — as Iron, Phosphorus, Soda, Potash, etc. ; in an- 
other the digestive apparatus requires stimulation ; in 
another special stimulants are required -to increase sym- 
pathetic innervation ; in another special means to give 



STUDY OP DIAGNOSIS. 311 

a right circulation and temperature ; in another stimu- 
lants to the formative cells by remedies and exercise ; 
and in others still the cure conies from stimulating the 
processes of waste and excretion, thus getting rid of 
old and feeble forms. 

The consideration of spanhceniia, or poor blood, is 
hardly necessary here, because it is included in the 
general term ansemia. Whilst it is possible to have a 
normal amount of blood, yet poor in some of its ele- 
ments, this is a rather rare condition. It will be known 
by the full, limp, inactive tissues, the full, blue veins, 
the full pulse without power in its stroke, and the ten- 
dency to dropsical effusions. It is really a worse con- 
dition than a simple ansemia, and requires more care in 
its treatment. As we employ means to increase the 
formation of blood, and add those elements necessary 
to its proper structure, we at the same time wish to get 
rid of the old stock', and the safest way to do this is by 
well regulated exercise and gentle stimulation of the 
apparatus of excretion. 

As remarked under the head of ansemia, special con- 
sideration is always given to a want of some of the ele- 
ments of blood, and to the means which will restore 
them. This is the basis of the treatment called restora- 
tive. If the blood requires Phosphorus, it will not do 
to give it Iron, as when it requires Iron it will not do 
to give it Sulphur or a bitter. The special symptoms 
heretofore named, showing these defects, should be 
closely studied. 

But the blood may be bad, or changes may be going 
on within it which will work its destruction. You may 
say that " bad blood " is a popular myth, and does 
well enough to base a nostrum advertisement upon, but 



312 STUDY OF DIAGNOSIS. 

it will hardly do for specific medication (?) There you 
are wrong, for ' ; bad bloud " is a real, tangible entity, 
with definite expressions, and a definite therapeutics. 
How will we recognize it? Assuredly in the ordinary 
way, by an inspection of it where it shows at the sur- 
face, by any material (secretion) that is drawn from it, 
and by wrongs in the nutritive function which is based 
upon it. When you think of these methods for a 
moment you will see that they have a physiological 
basis, are plain, and eminently practical. 

In acute disease we are more interested in those 
changes going on in the blood which we call septic, 
than in any special material contained within it, and 
these changes are more readily recognized by exuda- 
tions than other means. Attention has already been 
called to the secretions and deposits upon the tongue, 
as evidencing the condition of the blood. We find that 
all exudations that might be called dirty, and all changes 
in color toward brown and black, might be regarded 
as certain evidence of sepsis, and of the impairment of 
the blood. We put the proposition in this form — " as 
are the secretions of the mouth (notably the coating 
of the tongue) dirty or of deep color, so is the intensity 
of sepsis, and the death of the blood." In so far as the 
term typhoid is applicable to sepsis, these sj-mptoms are 
among the most prominent in typhoid diseases. 

Any exudation will serve to show the character of 
the blood as well as the coating upon the tongue. The 
discharges from the bowels and of urine, the sputa in 
disease of the respiratory apparatus, the lochia in puer- 
peral disease, the " washings-of-meat" discharges in 
dysentery, the secretions of an ulcer, the sanies of an 
injury or surgical operation, all tell the story explicitly. 



STUDY OF DIAGNOSIS. 313 

It is not possible to get a good secretion or exudation 
from septic blood, and the character of the one will 
show the condition of the other 

In some forms of chronic disease there is effete or 
imperfectly elaborated albuminoid material in the blood 
in considerable quantity. It serves to lower the char- 
acter of this fluid, and to impair all vital activities, and 
by influencing the nutrition of structures it gives rise 
to local disease. This bad blood has been a basis for 
the administration of the various compounds called alte- 
rative, so extensively employed b} T the profession, and 
also for nostrum venders, and no doubt the treatment 
adopted, by increasing waste and nutrition, has cured 
many cases. 

The evidence of bad blood is best found in wrongs of 
excretion and of nutrition. There can not be a wrong 
of this character Avithout an effort upon the part of the 
skin, kidneys and bowels to remove the unpleasant 
material, and we will usualtyfind that all three of these 
emunctories show a lesion caused by the effort, though 
one may suffer more than another. In the case of the 
skin it manifests itself in cutaneous disease, taking the 
forms of the exanthemata in the simpler cases, and the 
graver forms of the pusfulse, squamae and tuberculae, 
when the lesion is more persistent and severe. This 
fact has long been recognized, in so far as the treat- 
ment of skin diseases has embraced means for remov- 
ing effete and unpleasant materials from the blood. 

We frequently hear it remarked, " I know my blood 
is bad, because my flesh does not heal easily, and 
wounds and scratches inflame and suppurate." True 
there is something wrong here, and it maybe "bad 
blood," according to our definition above. At least in 
27 



314 STUDY OF DIAGNOSIS. 

a large number of cases, a treatment that looks to the 
increase of excretion, and better digestion and blood- 
making, removes all the unpleasantness. In the re- 
maining cases some special material of the blood is 
wanting, frequently Lime, sometimes Soda, Potash, 
Phosphorus, etc. 

In some cases the urinary apparatus is the special 
seat of. suffering. The entire apparatus is irritable, and 
the urine contains an abundance of ammoniacal com- 
pounds, and gives characteristic deposits. The effort at 
removal may be continued by these organs, until severe 
disease is induced, as seen in some cases of chronic in- 
flammation, and an occasional case of degeneration. 
The bowels always suffer more or less, indeed 1 hardly 
think It possible that this condition should continue 
long, without a loss of regularity in defecation, and a 
change in the character of the stools. 

The lesions of nutrition may take the form of de- 
generation, or of deposits. In the one case Ave have 
the S i ymptoms heretofore described, of enfeebled func- 
tion, and a want of expression in the soft tissues. In 
the other comes the evidence of local disease, enlarge- 
ment preceding inflammatory action, which runs a very 
irregular course. The last is so important an evidence 
that it is well to read it over. Whenever swelling 
and change in the form and functions of a part precede 
inflammatory action, there is a wrong of the blood, and 
means must be emploj^ed to remove the unpleasant 
material by excretion, and to provide for better blood- 
making. 

In place of thinking of certain remedies called " alte- 
rative," which act in " an insensible and inexplicable 
man/ier," it is process of cure. 



STUDY OF DIAGNOSIS. 315 

The bad material is to be removed, and good material is 
to be introduced in its place. We wish to know 
whether it is necessary to employ means to stimulate 
retrograde metamorphosis, by exercise or medicines, 
to increase the processes of combustion, to employ 
remedies that modify and arrest the septic processes, 
or to use such as increase excretion It is possible that 
the habits and surroundings of the patient must be 
changed before a cure is effected, or that he should 
have better food, better digestion, or better blood- 
making. In thus getting a better blood, there is less 
tendency to depravation. 

THE CIKCULATIOJST OF THE BLOOD. 

Among the most common lesions in disease are 
wrongs of the circulation of the blood. We may state 
it as an axiom that the condition of health requires a 
circulation normal in time and character, and just in 
proportion as we have a change from this normal 
standard we have severity of disease. The time of the 
pulse varies greatly in different individuals in a state 
of health, in the adult having a range of from 50 to 90 
beats per minute, yet in its other characteristics it is 
pretty uniform, and can hardly be mistaken. The 
finger on the pulse is trained to determine lesions of 
the circulation, and should rarely make any mistake. 

The wrongs of the circulation may be general or 
local, and classified under the three heads, excess, de- 
fect and perversion. The first has reference to rapidity, 
the second to an impairment or checking of the circu- 
lation, and the third may embrace cases in which the 
circulation is not uniform, or is irregular. 



316 STUDY OF DIAGNOSIS. 

Increased frequency of pulse is one of the character- 
istic symptoms of fever, and is usually associated with 
a proportionate increase of temperature. As a rule we 
estimate that ten pulsations represent 1° of tempera- 
ture — that is for each degree of increased temperature 
we may expect to find an increase often pulsations per 
minute. There are many exceptions to this rule, the 
increased frequency of pulse being sometimes more, 
sometimes less, and indeed sometimes showing but 
little relation. As a rule, increased frequency of pulse 
represents gravity of disease, and we are accustomed 
to think of it as an unpleasant symptom. As is the 
frequency of the pulse, so is the arrest of secretion, the 
increase of heat, the impairment of diges.tion and blood- 
making, the arrest of nutrition, the development and 
progress of sepsis, the progress of inflammatory dis- 
ease, and the danger to life, local and general. Hence 
the importance of means which influence the circula- 
tion, reducing its frequency without impairing its free- 
dom. 

Frequency of Pulse may be the basis of fever or 
inflammation, and when the pulse is brought down to 
a normal standard all the other phenomena of disease 
may disappear. Thus we often observe under the in- 
fluence of the special sedatives, that as the frequency 
of pulse is reduced, the temperature falls, the nervous 
system is relieved, the skin softens and becomes moist, 
the urine is increased, the bowels move of themselves, 
and the appetite returns. Or. in case of inflammation, 
the pain ceases, there is less heat, redness and swelling, 
and resolution rapidly progresses to complete restora- 
tion. These results are so common, that we are sur- 
prised in some seasons and in some cases to find that 
the sedatives do not seem to produce sedation. 



STUDY OF DIAGNOSIS. 317 

This brings up the important point in the study of 
disease — that there is a first and predominant wrong 
upon which the entire morbid process rests. In some 
cases, as in the instances given, this is so markedly the 
case that when we have removed this, the whole disease 
rapidly fades away. But in others this simply paves 
the way for the doing of something else, and this again 
for the restoration of other functions, and thus a suc- 
cession of means may be required in a single case. 

It will not do to say here, I have frequency of pulse, 
and my patient requires a sedative, taking any one of 
this class at random. The ten or a dozen remedies 
grouped under this head are not alike, and can not be 
used one for the other. It is true that we may so sub- 
stitute Yeratrum and Aconite in many cases, but even 
these had better be given according to the special indi- 
cations heretofore named — Yeratrum when the pulse is 
full, Aconite when it is small. Then we have Digitalis 
when the impulse is feeble, Lobelia when it is op- 
pressed and the artery is turgid with blood, G-elsemi- 
num when it is full and vibratile, Belladonna when it is 
full, soft, and without strength, etc. For these indica- 
tions and others, the reader is referred to a former con- 
sideration of the pulse as an element of diagnosis. 

Slowness of Pulse is not a common symptom in 
disease, but is occasional^ met with in chronic disease. 
It indicates a want of innervation, or excitability of 
parts supplied from the sj^mpathetic. The wrong may 
be found in degeneration of tissue, or simplj T a want of 
waste and nutrition, the tissues becoming old and in- 
active. In some cases the pulse will be slow when the 
patient has remained quiet for some time, but is in 
creased in frequency upon exertion. 



318 STUDY OF DIAGNOSIS. 

These cases will be benefited by the use of small 
doses of Lobelia, Digitalis, or Ergot, with the use of 
means to stimulate increased waste and nutrition. 

Changes in the character of the pulse are of very fre- 
quent occurrence, and many of them have already been 
named in connection with special remedies. In most 
severe diseases change in the character of the pulse 
will be found associated with frequency, and will prob- 
ably point out the sedative which will be found most 
useful. As heretofore stated, our examination of the 
pulse has reference to size, the movement of the mass 
of the blood, the impulse of the wave, its length, gen- 
eral character and termination, and the inter wave- 
current. A reference to anj^ sphygmographic illustra- 
tions will show that there is very great variation in all 
of these, and that thej^ do represent definite pathologi- 
cal conditions. 

Irregular distribution of blood is frequently met with 
in disease, and a popular expression in treatment is, 
" equalize the circulation." Some have laughed at the 
expression as being indefinite, unscientific, and partak- 
ing of the character of " old women's " medicine. But 
there is no plainer pathological fact than that the cir- 
culation of blood is unequal in many instances — here 
too much blood, there too little — a want of circulation 
to the extremities and surface, too much blood in the 
cavities of the body. That such inequality is the cause 
of disease is very easily shown by many examples 
Every one will recollect the cold feet and chilled sur- 
face that attends an ordinary bad cold, and wil! recall 
the local and general wrong that comes from a similar 
condition at the period of the menstrual flow, very 
greatly increased by the local stasis of blood in the 



STUDY OF DIAGNOSIS. 31 & 

uterus if the flow should be stopped. Many can recall 
cases of chronic disease, associated with cold feet and 
a tendency to chilliness of the surface from imperfect 
circulation, and they will recollect that such cases were 
very intractable. Some will recall cases of pneumonia 
or of typhoid fever, in which an irregularity of the cir- 
culation, and a tendency to accumulation of blood in 
the cavities, and a want of blood to extremities and 
surface were prominent features, and they will recall 
the gravity of such cases. 

As the mind recalls these well-known facts, the im- 
portance of equalizing the circulation will be seen. 
If in the commencement of a cold, means are employed 
to give an equally vigorous circulation to surface and 
extremities, the mucous membranes cease to suffer If 
in chronic disease we so improve the circulation that all 
parts receive an equal quantity of blood, we have ac- 
complished one of the essential things necessary to re- 
covery. If in severe local disease, or the graver acute 
affections called typhoid, we find an irregular distribu- 
tion of blood and heat, getting well will probably de- 
pend upon our abilit}^ to rectify this wrong. 

The Local Lesions of the Circulation that interest 
us most are embraced under the head of fry perse mi a, or 
an excess of blood in a part. This has special reference 
to the capillary circulation, though arteries and veins 
are involved to a limited extent. The condition of 
local hypersemia is easily understood and recognized. 
In health the mass of capillaries are not full, indeed it 
is impossible that they should be full at once. If there 
is an increased amount of blood in a part, with its 
motion unchanged, there will be increase of size — swell- 



320 STUDY OF DIAGNOSIS. 

ing— redness, if the part is superficial, and increase of 
temperature and sensitiveness. 

Whilst it is possible to have the condition above 
named, it is uncommon. As a rule there is a change in 
the rapidity of the circulation as well. Thus we divide 
hyperemia into two varieties, active and passive— in 
the one there is excess of blood in a part with its move- 
ment increased, and in the other excess of blood in a 
part with its movement diminished. We call the first 
determination of blood, and the second congestion. It 
will not do to mistake these pathological conditions, as 
the treatment of one is almost the opposite of that of 
the other. 

The cause of determination of blood is one — irrita- 
tion — ubi ivritatio ibi fluxus ; and the condition of the 
part is one of excitation. The symptoms are very 
clear — there is swelling, heat, increased sensitiveness, 
and redness. In 'minor degree the functional activity 
of organs and parts is increased ; but when in excess, 
though the part is excited, the function is diminished. 

If now we compare with this the condition of the 
capillary circulation in congestion, we will see that 
there is much difference. In this the capillaries are 
filled with blood, but the movement of the blood is 
sluggish, or entirely arrested in some vessels. The 
active life of the part is impaired to the extent of the 
impairment in the circulation, and all the expressions, 
show dullness and want of functional activity. 

Whilst there was but one cause for determination of 
blood, in congestion we may have three. The principal 
one of these is an impairment of the life of the part — 
the structures being enfeebled the capillaries yield to 
the vis a tergo of the blood. In some cases an irritation 



STUDY OP DIAGNOSIS. 321 

of the part is a first cause, determining a greater amount 
of blood to it than its weakened vessels can withstand. 
In other cases an obstruction to the return current by 
way of the veins, is a principal cause. 

As before named, the symptoms are all of impaired 
function and oppression, and when we compare this 
with the excitation of the active state of determination 
of blood, the distinction will be clear. We say that 
the sensations are of fullness, weight, dullness, and if 
there is pain it will partake of these characters. The 
objective symptoms when near the surface are of swell- 
ing, and an increased redness that has not the bright- 
ness of the active circulation ; the temperature may or 
may not be increased. 

If we take some examples of the two conditions, the 
subject ma} 7 be clearer. In determination to the brain, 
there is a flushed face (bright), bright eyes, contracted 
pupils, increased temperature, and excitation of func- 
tion — the patient being excited, restless and sleepless. 
In congestion the. face is usually flushed (dusk) 7 , pur- 
plish or livid), the eyes are dull, pupils dilated or im- 
mobile, the mind is sluggish and the patient inclined 
to coma. If we take the lungs, we find in determina- 
tion a rapid, uneasy respiration, characterized by quick 
movements of the walls of the chest, and the patient 
shows the excitation in the sharp, forcible cough, and 
frequent change of position to get relief. The func- 
tional activity of the lungs being increased, the color 
of the blood when it reaches the surface is brighter than 
usual, and the surface is therefore flushed. In conges- 
tion, the movement of the chest is sluggish, labored and 
oppressed, and the cough has a like dull and oppressed 
character. The function of the lungs being diminished 



322 STUDY OF DIAGNOSIS. 

the surface is inclined to be dull, dusky, or livid. If 
we take a diarrhoea as an example, the symptoms are 
quite as clear. With determination of blood, there is 
marked uneasiness, and the evacuations are unpleasant 
or possibly painful, and attended with some tenesmus. 
From congestion, the bowels are tumid, have a sensa- 
tion of weight and fullness, and the discharges are free 
and without uneasiness. 

Whenever we find these two conditions, the symp- 
toms will have the same character, and will be shown 
by the sensations, and by the function of the part. In 
determination there is the feeling of increased activity, 
and in congestion the feeling of impaired activity; in 
determination there is excited function, in congestion 
impairment of function. 

As the cause of determination is irritation of the part, 
any agent which will remove this irritation becomes a 
remedy. As the circulation in its entirety is controlled 
by a system of nerves, a lesion of a part may some- 
times be best relieved by an action upon the whole 
through the sympathetic. Determination of blood to 
any part may be relieved by the use of Yeratrum, 
Aconite and G-elseminum. Other than these general 
remedies, we select those that influence the special part 
affected, and that remove irritation. In determination 
to the brain we use G-elseminum ; to the lungs Yera- 
trum or Ipecac; to the kidneys G-elseminum; to the 
bladder Eryngium ; to the bowels Aconite and Ipecac ; 
to the uterus Aconite and Macrotys. In so far as we 
use local applications the}^ are selected in the same 
way: wet packs, poultices, fomentations, enemata, in- 
halations, etc., are selected with reference to their seda- 
tive character. 



STUDY OF DIAGNOSIS 323 

In congestion the part requires stimulation, especially 
stimulation through the sympathetic. It may also be 
influenced to a greater or less extent b}' remedies 
stimulating the circulation at large. Thus Belladonna, 
Lobelia, and to some extent Aconite, are of value in all 
cases of congestion. Other remedies are selected with 
reference to their action upon the part, as stimulants 
or excitants. In congestion of the brain we use Bella- 
donna; in congestion of the lungs or of the heart, 
Lobelia; in congestion of the abdominal viscera, Nux 
Vomica; in Congestion of the kidnej^s, Belladonna, etc. 
In selecting local applications we observe the same 
rule ; whatever their form, they should be excitant to 
the part. In studying the action of remedies, we first 
wish to know where they act, and second the kind of 
action. If a part is diseased, we wish a remedy that 
acts upon that part particularly, and which does that 
which is necessary to restore it to health. In the case 
of determination of blood — the active circulation — we 
want a remedj 7- that will remove irritation, and the un- 
due excitation of its circulation ; in congestion we want 
a remedy that will increase the life of a part, or that 
will give the necessary stimulus to the capillary vessels. 

According to Dr. Williams, inflammation is a local 
hyperemia, with the movement of the blood partly in- 
creased and partty diminished. We study this process 
of disease, with reference to its cause, the lesion of the 
circulation, the exudation, and the result or termina- 
tion. The cause is one, irritation with such impairment 
of vegetative life. From the irritation comes an in- 
creased circulation to the part, the capillaries are filled 
with blood, which in some moves sloAver and slower, 
until the circulation through them i* arrested ; and yet 



324 STUDY OP DIAGNOSIS. 

in others the movement of the blood still continues 
rapid. As the capillaries lose their strength and be- 
come thus filled, the fluid portion of the blood is exuded 
into the intercapillary spaces, or upon free surfaces. 
This completes the pathological process, and we next 
study its result upon the life of the part. If the origi- 
nal lesion has not impaired the vegetative life too much, 
or the lesion of the circulation has not been too great, 
we find that after a time these minute vessels regain 
their tone, and the circulation is re-established in them. 
As the current of blood commences to flow through 
them, the material exuded is drawn into the current 
and carried away, thus leaving the part in its original 
condition. This termination is called "resolution," 
and is the result most to be desired in all cases. But 
if the life of the part be so impaired by the cause, that 
it can not renew itself; or if the impairment of the cir- 
culation be so great as prevent its receiving the 
necessary amount of oxygen, and the removal of car- 
bonic acid gas. then it must die and be removed. This 
death and removal takes place in two ways — by sup- 
puration, and by gangrene or mortification. In sup- 
puration the process of death is modified by a lower 
form of life — the production of pus-cells, from the 
formative cells of the part, and thus the remainder of 
the body is protected in part, and repair facilitated. 
But if the impairment of life is greater than this, the 
part dies, and is removed en masse, by the suppurative 
process when the tissues still retain sufficient life. 

The symptoms of inflammation, according to the old 
authorities, are pain, heat, swelling and redness, and 
for superficial parts these are characteristic and definite, 
but for internal and concealed parts we are obliged to 



STUDY OF DIAGNOSIS. 325 

rely upon the first, and the evidences of impaired func- 
tion, and the influence upon the general health. 

Pain is a very constant expression of inflammation, 
though it is very common from other causes. It varies 
from simple uneasiness from over-excitation, to the 
sharpest and most severe suffering, and its intensity is 
not to be taken as the measure of inflammatory action 
in any case. It becomes symptomatic of inflammation 
onl}< when there is evidence of a wrong circulation, and 
increase of temperature, general or local. 

Heat is a constant symptom, and much more reliable 
than pain. It may be' but local in superficial inflam- 
mation, or when but a small and unimportant part is 
affected, but is general when an important part or much 
tissue is involved. In some cases the patient's sense of 
heat may be taken as evidence, though this is very 
liable to error. As a rule the temperature of an in- 
flamed part will not rise higher than 102°, unless there 
is a corresponding elevation in the temperature of the 
body, and there is rarely more than one or two degrees 
difference between the general and local temperature. 
The sense of heat, when the hand is placed upon a 
superficial inflammation, is due in part to arrest of 
secretion from the skin, which is also the cause of any 
difference there may be in temperature. 

Swelling is also a constant sj^mptom, though not so 
marked when free surfaces are involved, or very dense 
tissues. It is not a reliable S}nnptom, however, for it 
may be due to changes in the nutrition of a part, to 
growths, deposits and exudations. To be of any im- 
portance in diagnosis it must be associated with evi- 
dences of derangement of the circulation, and with in- 
creased heat. 



326 studt or diagnosis. 

Redness is only an evidence in siq^erficial inflamma 
tion, and is due to the presence of a large number of 
red globules. It is deeper than in determination of 
blood, though it may be simulated by some rarer con- 
ditions of the skin. 

Among the prominent and most valuable symptoms 
of inflammation are wrongs of function ; these are con- 
stant and characteristic. In the early stage of excite- 
ment the functional activity of some parts will be in- 
creased ; but in a majority it simply shows excitement 
and is really impaired. As the capillary stasis in- 
creases, and exudation occurs, the function becomes 
more and more impaired, until in some cases ifc is com- 
pletely arrested. Thus in inflammation of the brain, 
we have at first great mental excitement, then delirium, 
then probably incoherent (muttering) delirium, and 
finally from exudation — coma. In this case the symp- 
toms of the first and second stages are almost opposite — 
active delirium and coma. In inflammation of the 
lungs we find at first increased activity and a rapid oxi- 
dation of the blood ; but in the second stage there is 
oppression, and an imperfect aeration of the blood. In 
inflammation of the liver, there ma} T be at first stage an 
increase of biliary secretion, whilst in the second there 
is complete arrest. So in inflammation of the kidneys, 
the first excitement produces increased secretion of 
urine, whilst the second may arrest it entirely. 

The different phases of the' inflammatory process and 
its results, require care in diagnosis. Recognizing the 
presence of an inflammation, we want to know the 
danger to the life of the part, and to the life as a whole. 
In this respect it may be said, that those cases of but 
moderate excitement are most favorable. When the 



STUDY OF DIAGNOSIS. 327 

vascular and nervous excitement are extreme we may 
anticipate an unfavorable result, as well as when we 
Lave marked swelling and redness, with impaired sen- 
sibility and arrest of function. The sensation given to 
the touch will be most reliable in external inflamma 
tions; the greater the departure from the normal stand 
ard, the greater the danger to the tissues. 

Suppuration is announced by an increased fullness oi 
the tissues, a sense of increased tension, and a change 
in the character of the pain, which becomes throbbing. 
If but a moderate amount of tissue is involved in an 
unimportant part, suppuration is followed by relief of 
the general symptoms, but when considerable tissue is 
broken down, or important organs are involved, it is 
frequently ushered in with a chill, and attended by a 
fever having somewhat the character of hectic. 

Gangrene of external parts is announced by the 
change in color — purplish or black — by coldness, and a 
want of sensibility. Internally it is announced by 
great prostration, the subsidence of pain, loss of sensi- 
bility, and a soft, feeble pulse. 

The general sjmiptoms are those of fever. The cause 
of inflammation is depressing to the life of the indi- 
vidual as well as to the life of the part, and when con- 
siderable structures are involved the expressions are 
very distinct. The first influence gives the listlessness, 
languor and loss of function; this culmina'<s in ;i chill 
or rigor ; and this is followed b} 7 the symptoms of 
febrile reaction — frequent pulse, increased temperature, 
arrest of secretion, and derangement of the nervous 
system. 

In the severer cases of inflammation these general 
Symptoms are as pronounced as in fever, and it is some- 



528 STUDY OF DIAGNOSIS. 

times difficult to determine a local lesion, except by 
close examination and attention to special symptoms. 
If care is used, however, a special wrong of function 
will attract attention to a part or organ, and symptoms 
of inflammation will be detected. 

The close relationship between fever and inflamma- 
tion should not be forgotten, and indeed it is well in 
practice to recognize them as requiring the same treat- 
ment ; an inflammation is fever of a part. The reme- 
dies for fever are remedies for inflammation, and in 
many cases they are the best and most direct we have. 
If, in the majority of cases, the pulse is brought down 
to a normal standard, the temperature reduced, inner- 
vation normal, and the secretions restored, the inflam- 
matory process will cease, and if the life of the part 
has not been too much impaired, resolution will be 
rapidly effected. 

In studying the treatment of inflammation it is well 
to bear in mind the different phases of the morbid pro- 
cess. First, irritation and determination of blood; 
second, impairment of capillary circulation until its 
final arrest, and lastly, the impairment of the life of 
the tissues from this and the exudation. The irritation 
may continue through the entire progress of the in- 
flammation, and thus will continuously attract the blood 
to the part, whilst from the commencement there are 
marked evidences of impairment of tissue life. 

Anything that will lessen or remove irritation will 
prove a remedy in inflammation. Take away the irri- 
gation, and you take away the cause of an excited cir- 
culation of blood to and in a part. The general means 
have been already referred to, but some of them are 
local as well. - The sedatives, Veratrum and Aconite, 



STUDY OF DIAGNOSIS. 329 

influence the inflammatory process directly, wherever 
it may be located. So do the indirect sedatives of the 
olden lime — the nauseant emetics, and the more power- 
ful diaphoretics. 

In the selection of local means, we must closely 
value the inflammatory process, and determine the 
kind of influence most desirable. It may be directly 
sedative, removing irritation, and in some instances 
may be depressant. In others, whilst an object is to 
remove irritation, we also keep in view the greater ne- 
cessity of stimulation to the capillary circulation. And 
in many we keep in view, as a principal object, such 
treatment as will increase the life of the tissues. 

When we have determined by an examination that 
the inflammation must terminate in suppuration, we 
should not forget that resolution goes on at the same 
time, and that it is our business to confine the suppu- 
rative process to as small a proportion as possible, and 
to obtain resolution as far as is practicable. The treat- 
ment is just the same as in mortification ; we wish to 
restrict the death to as small a portion as possible, and 
Ave do it by strengthening the life of the tissues. 

The means named are those which might be em- 
braced under the head of physiological medicine, and 
give us an excellent basis of treatment in many cases. 
In some we have special means, the action of which 
can not be explained in this way. These remedies are 
indicated by some special expression of disease, and as 
we have already seen, they prove curative in very 
diverse (seemingly) conditions of disease. I need but 
instance the action of Tincture of Muriate of Iron in 
erysipelas ; the action of Ehtis, Bryonia and Macrotys 
and some other agents in the arrest of special inflam- 
28 



330 STUDY Or DIAGNOSIS. 

matrons, or the special action on individual parts or 
associate functions, as Phytolacca in mammary inflam- 
mation, or in disease arising from nursing. 

INNEKVATION, 

We divide the nervous system into three parts, for 
study— the brain, the spinal cord, and sympathetic* 
The first is the organ of conscious life, the second of 
automatic movement, and the third governs and asso- 
ciates the functions of vegetative life. The functions 
of the brain are reason, emotion, volition and sensation ; 
of the spinal cord, the co-ordination of muscular action, 
and the functions of respiration, defsecation and urina- 
tion, and expulsion of the uterine contents ; and of the 
sympathetic, digestion, circulation, nutrition, and secre- 
tion and excretion. 

Lesions of innervation may be due to a change in the 
condition or structure of the nerve centres, or to some 
lesion external to these. The more common lesions are 
of the circulation, and we have them from the two 
opposite conditions of an excited circulation — too much 
blood in a part, or an enfeebled circulation — too little 
blood in a part. Whenever Ave find these lesions, this 
is the first question Ave ask. and usually the symptoms 
of hypersemia or anaemia will be distinctly marked. 
A physiological treatment will be based upon this, to a 
considerable extent. If we have hjpera?mia Ave use 
remedies which lessen excitation, if it is anaemia Ave 
emploj^ such agents as stimulate and give a more v\g- 
orous circulation. In the first cases the ti eaiment may 
be temporarily depressant, in the second '^ }* always 
restorative and tonic. 



STUDY OF DIAGNOSIS. 331 

Delir.um iii acute disease is readily recognized. 
The inability to reason rightly, and the illogical and 
unreasonable expressions tell the story clearly. We 
say delirium is active, it is passive, it is coherent, it .s in- 
coherent — taking the entire range of that active con- 
tinued expression, in which it is almost impossible to 
control the patient, to the dreamy delirium of typhoid 
fever, in which the patient is calm and still, or the mut 
tering delirium that soon passes into coma. 

But we are not so much interested in the expression 
of delirium as we are in the symptoms indicating the 
physical condition of the brain. We Avant to know 
whether there is an active circulation, or an enfeebled 
one ; whether the patient can bear temporary depres- 
sants, or requires stimulants and restoratives. The 
practitioner will recognize the pertinence of this in- 
quiry, as it points the way to the selection of direct 
remedies. In the first case we use the sedatives and 
associate means that relieve excitement, and the special 
remedy, Grelseminum. In the second we use Quinine, 
stimulants, restoratives, tonics and food. 

It ma}' be remarked here, that in addition to the 
means selected in this way, any remedy which may be 
indicated by special symptoms, is a remedy for delirium. 
Thus we see a delirium rapidly disappear under the use 
of an acid, an alkali, one of the antiseptics, Ehus, and 
other agents heretofore spoken of. The two methods 
may be sometimes combined ; though, if the symptoms 
indicating a single remedy are pronounced it should be 
first given. 

In delirium tremens, we also find two conditions of the 
brain as a basis for the wrong reason. A want of re- 
cognition of this fact has given us some queer medical 



332 STUDY OF DIAGNOSIS. 

V 

literature. For a time we will find our medical peri- 
odicals teeming with recommendations of stimulants, 
tonics and food as the means of cure: then for a time 
they will recommend a sedative and depressant treat- 
ment. It never seems to have impressed the profession 
that delirium tremens might arise from two opposite 
conditions of the brain — one in which the circulation 
of the organ is depressed, and the other in which it is 
too active — ■and yet this is very certainly the case. 

If we find our patient with sunken eyes, blanched or 
livid lips, cold extremities, and a small and feeble pulse, 
we know that he requires stimulants, and especially 
food. In the early stage of such a case we would ex- 
pect to arrest its progress by the stimulant action of 
Nux, Iodine and Hydrastis, and the use of beef-tea. 
We can see how it is that Capsicum in large doses 
should prove curative, and how small doses of Quinine, 
Opium and Camphor exert a beneficial influence. 

But if we find him with a florid face, full, bright eyes, 
increased temperature, and a full, hard pulse, we recog- 
nize a condition of undue excitement, and would hardly 
use the treatment just named, though it has proven 
successful in cases of delirium tremens. On the con- 
trary, we propose to select remedies which will remove 
the undue excitement of the circulation, and give rest 
to the brain. Thus we give full doses of Veratrum and 
Grelseminum, saline cathartics and diaphoretics, and 
possibly follow with Bromide of Potash and Chloral. 

If we study puerperal mania, or acute insanity, we 
find two classes of cases, as in delirium tremens. In 
one from exhaustive discharges, lactation, and starva- 
tion (the regulation toast and tea), we have a condition 
of anaemia. We find the face pallid, the eyes dull, the 



STUDY OF DIAGNOSIS. 333 

tongue broad and pallid, the pulse small and feeble, and 
the extremities cool. We at once recognize that this 
patient wants proper stimulants, tonics, restoratives, 
and food, and as we give them we find that there is a 
steady improvement. If we had employed the olden 
stereotyped treatment of purgatives and depletives, we 
would have had a funeral, or a case for the lunatic 
asylum. 

But in other cases we do find a flushed face, full, 
bright eyes, contracted tongue, increased temperature, 
a fall, hard pulse, and partial arrest of secretion. The 
case is just as clear as the first one, and we cure it by 
the use of the proper sedative, G-elseminum, and means 
which will restore secretion and excretion. In this 
case temporary depressants may sometimes be employed 
with good results. 

In chronic mania, the diagnosis of the physical condi- 
tions of brain and bodj r will be made in the usual way. 
All wrongs of function and structure are to be removed 
as far as possible, and the patient placed in the best 
possible healtb. Thus if there are special indications 
for any single remedy, this should be given. In some 
cases the action of such agents is very speedy and per- 
manent. 

With regard to the psychological treatment, but little 
need be said. It must be based upon this law of 
nature — " that in proportion as an organ or function is 
used it gains strength ; and as it is disused it loses 
strength." In so far as the morbid mind has material 
to feed upon, and has exercise, the insanity will be in 
creased ; and in so far as the normal functions of the 
mind are disused, they become enfeebled. The object, 
therefore, is, to call out the mind in orderly channels as 



334 STUDY OF DIAGNOSIS. 

much as possible, and to give as little cause for the ii 
sane manifestations as possible, that the one may gain 
strength and the other lose it. 

What has been said with reference to reason is appli- 
cable to the emotions, in so far as the necessity of re- 
cognizing the physical lesions are concerned. Emo- 
tional wrongs have a physical basis, and if perfect 
health can be restored, they will pass away. Indeed, 
permanent cures can only be effected in this way. 

The wrongs of the emotions may be in either of the 
three ways — excess, defect and perversion — but the first 
and last associated, are usually met with. The expres- 
sion is so distinct that it can hardly be mistaken; too 
great a manifestation and rapid alternation of grief, 
joy, hope, fear, exaltation, depression, etc., without 
sufficient or corresponding cause, tells the story. Hys- 
teria is the type of this class of diseases, though it in- 
volves other than the emotions. 

A defect in volition is often noticed as an element of 
mental disease, and as an attendant upon some other 
diseases. It is often remarked that the strong will is 
an important means of recoveiy — " that when one will* 
to get well, he Avill get well " — and every practitioner 
will have noticed the difficulty of managing those cases 
in which there was an indifference, or want of volition. 
The expression of the face will frequently give this in- 
formation before a word is spoken. The firm expres- 
sion of the muscles of the month and closure of the 
jaws is characteristic of strong will ; whilst the relaxed 
muscles of the mouth, and the general want of expres- 
sion, tells of enfeebled will. 

Recovery will frequently depend as much, or more, 
upon strengthening the will, as upon the use of reme- 



STUDY OF DIAGNOSIS. 335 

dies. If we can call it into action, by presenting addi- 
tional motives for its exercise, or by a judicious stimu- 
lation from attendants and friends, we find that it will 
grow by exercise, and that which Avas difficult to the 
patient at first soon becomes easy and natural. 

The brain receives impressions from the world with- 
out, and from the various parts of the body, through 
the apparatus and nerves of special and general sense — 
and this we call sensation. In the healthy body all 
sensations from it are pleasurable, and the use of the 
special senses is a source of pleasure. But in disease 
sensation is unpleasant, and a source of discomfort, and 
we designate it as pain. It is well to become thor- 
oughly conscious of this, by passing the various sensa- 
tions in review. To the sound eye, use is a pleasure, 
and we only know the organ through the pleasurable 
sense of vision ; the impulse of sound waves upon the 
ear is pleasurable ; so is the use of the sense of taste, 
and of smell. When we direct the mind to the appa- 
ratus of digestion, Ave find that it giA^es pleasurable sen- 
sations, in so far as it gives sensation at all ; the func- 
tion of respiration is pleasurable, and so is defecation 
and urination. 

When this sense of pleasure is lost, we may knoAV 
that an organ or part is diseased, though the discomfort 
may not tell us the quality or amount of disease. If 
the use of the eye becomes a source of discomfort, our 
attention is called to that organ as the seat of disease, 
and we at once make a proper examination to deter- 
mine its character. If the use of the ear is a source of 
discomfort, we at once conclude that it is the seat of 
disease, and Ave make the necessary examinations to 
determine its exact character. If there be discomfort 



336 STUDY OP DIAGNOSIS. 

in the sense of taste, Ave know there is a wrong in the 
mouth where these nerves are distributed, or of the 
digestive apparatus to which these nerves stand sen- 
tinel. If there be discomfort in the sense of smell, we 
at once conclude there is disease of the nasal cavities. 
So when there is discomfort from any apparatus or 
function — the throat, larynx, lungs, stomach, bowels, 
defsecation, urination, etc.. we know there is disease, 
and having our attention directed to its seat, we pro- 
ceed with the proper examinations to determine its 
character. 

Persons will sometimes have their first knowledge of 
organs or functions through discomfort and pain. The 
dyspeptic realizes that he has a stomach through pain ; 
the minister realizes that he has a larynx, when it has 
become irritable and painful by abuse; the location of 
lungs, liver, spleen, bowels, kidneys, bladder, uterus, 
etc., is first realized by many through the suffering of 
disease. 

It is well to bear in mind that pain may have two 
causes — it ma}' be due in principal part or in whole from 
disease of the part that suffers, or of the brain that re- 
ceives the impression. To determine this is an impor 
tant part of the diagnosis of pain. A little care in 
noting the expression of the face, the eyes, and the 
other functions of the brain will determine this in most 
cases, and this may be supplemented by a careful ex- 
amination of the part. 

The diagnosis between the pain of structural disease 
and neuralgia is usual iy made with ease. The absence 
of heat, redness and swelling, in any considerable de- 
gree, is usually sufficient, but in obscure cases it is well 
to carry the examination further to determine lesions 
of the blood, of nutrition, waste and excretion. 



STUDY OF DIAGNOSIS. 337 

General disease will give rise to the conditions of 
pain, and to a' considerable extent may be considered 
its cause. Thus, the vascular excitement and increased 
temperature of fever render the brain more sensitive 
to impressions, and the nerves more active purvej^ors. 
The sj'mptomatic fever that attends inflammation has 
the same influence in increasing pain. Thus, in those 
cases where pain is very severe, the means that lessen 
the frequenc}' of the pulse, diminish the temperature, 
and establish secretion, are the most effective to cure 
pain. 

When we study the condition of the brain as a cause 
of pain, we find that it is not one, as generally sup- 
posed, but two, possibly three. In one case we have 
evidence of vascular excitement in the flushed face, 
bright eyes, contracted pupils, and increased tempera- 
ture. And we meet this condition with Gelseminum, 
the sedatives, and possibly the saline diuretics and 
cathartics. In the second case we find the evidence of 
an enfeebled circulation in the pallid, expressionless 
lips, the dull eyes, dilated or immobile pupils, and pos- 
sibly the coolness of nose, ears and forehead — the gen- 
eral expression is of want of stimulus. In these cases 
we think of nerve stimulants, of Belladonna, Quinine, 
JSTux, Ammonia, etc. The feeling of dullness and in- 
clination to sleep attending some forms of pain is met 
especially by Belladonna and Ergot. The wrongs of 
perversion are not so easily determined, but with care 
we may find the indications for special remedies, some- 
times in the expression of the face, sometimes in the 
appearance of the tongue, and sometimes in the changes 
of the pulse. 

There is no doubt that many times the character of 
29 



338 STUDY OF DIAGNOSIS. 

the pain may point out the special remedy for the cure 
of the disease, though it is not as certain as other 
mean3 of diagnosis. If we could feel the pain, as we 
feel the pulse, it would be different, but trusting to the 
patient's uneducated senses, and his imperfect power of 
analysis and expression, we find it uncertain. If per- 
sons are trained to close observation, analysis and ex- 
pression in this regard, as in some Homoeopathic fami- 
lies, it may become very reliable. 

Lesions of spinal innervation are diagnosed from 
wrongs of function controlled by this nerve-center. 
Thus impairment of muscular motion may be referred 
to an enfeebled spinal cord, an exalted sensibility of 
muscles, to increased spinal innervation, whilst all 
forms of convulsion may be attributed to perverted 
spinal innervation. Among the important functions 
controlled from the spinal cord is that of respiration. 
We will sometimes find deficient respiration, that phy- 
sical examination will determine is not from structural 
disease, and we reach the conclusion that it is want of 
innervation. In acute disease we sometimes find this 
so marked, that respiration can not be carried on except 
through the influence of the will and the external re- 
spiratory muscles. We notice that so soon as the 
patient sleeps, respiration becomes more and more dif- 
ficult, until at last he is suddenly aroused by a feeling 
of asphyxia ; thus rest is prevented, and death may re- 
sult. In all these cases we think of spinal stimulants 
as remedies, Nux Vomica and Strychnine being the 
type — and increasing spinal innervation, we find our 
patient breathes better, and gets necessary rest. 

The lesions of excess are rather rare, but still they 
deserve close study. We will find it marked in some 



STUDY OF DIAGNOSIS. 339 

cases by excessive muscular irritability, so that the 
patient exhausts himself by over-exertion, or more fre- 
quently by that uneasiness which might be called mus- 
cular fret. In others the lesion is principally manifested 
in the respiratory muscular apparatus, giving frequent 
or irregular respiratory movements — respiratory fret — 
or sometimes severe and intractable cough from very 
slight internal irritation. In other cases we find the 
evidence in defecation and urination, giving frequency 
and some tenesmus, without corresponding internal 
disease. 

In these cases there is usually hyperemia of the cord, 
marked by a full, hard pulse, tense skin and muscuku 
structures, and rigidity or contraction in all the expres 
sions of the body. The remedies will be Verafrum 
Gelseminum, Sulphur in free doses, the saline cathartics 
and diuretics, the cold wet-sheet pack, alkaline bath, 
etc. 

In some rare cases, there is a condition of anaemia, 
and the patient requires Nux, Stiychnine, Quinine, 
Iron, Arsenic, stimulant baths, with restoratives and 
animal foods. 

The lesion of perversion gives us the entire series of 
convulsive affections, so frequently met with in the 
practice of medicine. In this case the spinal cord takes 
complete control of the body, and sets it into disorderly 
movement. How the wrong is produced, or what is 
its exact character, is not known, but when once it has 
obtained, the tendency is to its repetition. There is no 
difficulty in its recognition ; the complete arrest of the 
function of the brain, and the disorderly activity of the 
muscles is so marked that it can not be mistaken. 

Two causes of convulsions are recognized : the one 



340 



STUDY OF DIAGNOSIS. 



disease of the spinal cord ilself — intrinsic, the other a 
lesion of some other part — extrinsic. The exact condi- 
tions of the spinal cord are not well known, but we 
may recognize one of vascular excitement, and one of 
atony and impaired circulation. In the first the surface 
and face is flushed, the eyes bright and pupils con- 
tracted, the pulse somewhat full and hard, and the tem- 
perature usually increased. In the other the face is 
pallid or livid, the eyes dull, the pupils dilated in the 
intervals of spasm, the extremities cold, and the pulse 
small and frequent. There is a third case in which 
there is very evident congestion of the cord, and the 
face will be full and dusky, the eyes protruding, and 
the pulse full and oppressed. 

These cases are usually so well marked that the diag- 
nosis is not difficult, and a correct treatment is at once 
suggested. In the first case we use Gelseminum or 
Veratrum.or both. In the second ease we use Lobelia, 
Chloroform. Bromide of Ammonium, or the foetid gum 
resins. In the third case. Belladonna, Ergot, and pos- 
sibly Aconite; Bromide of Ammonium is sometimes an 
excellent remedy here. 

It is most absurd to think of treating all cases of 
convulsions with one prescription. Specific Medication 
never goes that far. it treats conditions of disease, and 
not names. The instance of convulsions furnishes a 
very good example of the necessity of accurate diag- 
nosis. 

It is well to note here that the spinal cord having 
formed a habit of convulsive action, has a tendencj^ to 
repeatthis at varying intervals, even though no change 
of structure, or disease of other parts can be found to 
account for it. In addition to the treatment for the 



STUDY OF DIAGNOSIS. 341 

convulsions, this habit, or tendency to recurrence is to 
be broken up, and we find in many cases that the 
longer the convulsive action can be postponed, the less 
disposition there is to its recurrence. In the treatment 
of some cases of epilepsy, this is a principal object, and 
any means which will even temporarily ward off an 
attack, becomes a part of the cure. 

The extrinsic causes deserve consideration, though 
many times they have ceased before we are called to 
treat the cases. If in infancy we find the gums swollen 
and purplish, a free incision over the coining tooth may 
relieve the convulsion at once. If green fruit or other 
irritant ingesta has proven a cause of convulsions 
through irritation of the stomach, an emetic will give 
the speediest relief. If it has come from irritation of 
the solar plexus, attended by pain — colic — Nux Vomica 
will give relief. If from irritating materials in the 
intestine, cathartic enemata may be of great service. 
If from partial suppression of urine, the hot packs over 
the loins, with G-eiseminum, will be the treatment. 

Worms may be a cause of convulsions, and yet I do 
not think it advisable to give worm medicines, until all 
symptoms of nervous irritation and convulsions have 
been removed. Otherwise the additional irritation from 
the worm medicine may prove fatal. 

In epileps 4 y the original cause may pass away in a 
few hours, or it may persist for years. Thus in some 
cases an epilepsy will arise from a temporary irritation 
of the stomach, the intestinal canal, or the reproductive 
apparatus, and no traces of the lesion will be found 
when we are called to treat the patient. But in other 
cases the lesions will persist, and their occasional or 
periodical increase will determine the convulsion. Thus. 



342 STUDY OF DIAGNOSIS. 

menstrual derangement may prove a continuous cause, 
as will disease of kidneys, stomach, bowels, and some 
other parts. In all eases the examination is carefully 
made to detect local legions, and when found, means are 
employed to remove them as part of the cure. 

The study of paralysis might follow the consideration 
of the lesions of the brain and spinal cord, as it may 
embrace either or both. When the lesion is of one of 
the hemispheres of the brain, the paralysis is of one- 
half of the body, divided vertically, and is called hemi- 
plegia. When it is of the spinal cord, it is of the lower 
portion of the body, the division being horizontal, and 
involves all parts below the seat of disease ; this is 
called paraplegia. When of bat limited extent, we call 
it local paralysis, and we trace it to a lesion in the 
course of the nerves, or to a limited disease of the cen- 
tre from which the nerve has its origin. 

We must not suppose that when we have diagnosed 
a paralysis by the impairment or total loss of motion 
or sensation, or both, that we are ready to make a pre- 
scription, and that all that is necessary to be done is 
to stimulate the nerve centres or the affected parts, by 
Strychnia, or electricity. We want to know the char- 
acter of the wrong, both of the nerve centres and of 
the general health, and when Ave have determined this 
we can prescribe intelligently. 

In hemiplegia we will find two conditions of the 
brain. In one case we will have a flushed face, bright 
eyes, contracted pupils, increased temperature, im- 
paired excretion, and a pulse characterized by fullness 
and hardness. Surely no sane person would treat this 
case with ZSTux or Strychnine? On the contrary, we 
use the proper sedative, Gelseminum. means to establish 



STUDY OF DIAGNOSIS. 343 

secretion, and possibly suppurative counter-irritation. 
In a second case the face is swollen and dusky, the lips 
livid or purple, the eye dull, pupils dilated or immobile, 
and the pulse full and oppressed. This patient, wants 
Belladonna, Ergot, Bromide of Ammonium, and wet- 
cups to the spine, with, possibly, stimulating cathartics. 
In a third case the head is cool, the face lacks expres- 
sion, and the pulse is nearly normal, but wants force. 
Every symptom points to anaemia of the brain, and to 
the want of restoratives. Here we give Nux or Strych- 
nine as nerve stimulants, the bitter tonics, good food, 
and use electricity for its stimulant influence. 

The diagnosis will take the same course in acute 
paraplegia, and the same means will be used in its treat- 
ment When it has been preceded by an injury, or by 
inflammation, we wish to determine as nearly as pos- 
sible the condition of the part, and whether or not the 
lesion has destroyed the nerve structures. Even here 
the treatment may be rational. We do that which 
needs doing, whether it be to promote the removal of 
effusion of organized lymph, or of water, or b} T an in- 
crease of waste and nutrition gradually renew the dis- 
eased structures until they are capable of doing their 
work. 

Wrongs of the sympathetic nervous system are so in- 
timately associated with lesion of the vegetative func- 
tions that we find difficulty in separating them. Pos- 
sibly it is only where an important part or the whole 
of this system is involved, that it requires special studjr. 
We may classify these lesions as an excess, defect, or 
perversion, though the excess is more an undue excita- 
tion than an increase of power. 

We will find this excess marked in an unnatural and 



344 STUDY OF DIAGNOSIS. 

unaccountable frequency or hardness of pulse, and an 
unpleasant irritability of the organs of digestion and 
secretion. There can be no improvement until we can 
have better innervation. In such cases Veratrum has 
a most excellent action, and followed by Arsenic, will 
frequently effect cures in very stubborn cases. 

Defect is marked by a feeble circulation, th 3 artery 
giving the sensation of a want of tone or elasticity, 
and all the vegetative functions are feebly and imper- 
fecta performed. That it is not due to a wrong of the 
organs themselves is readity determined by other symp- 
toms. In these cases, Phosphorus, Sulphur, Iron, Cod 
Liver Oil, Pulsatilla, Digitalis, Aconite, are especially 
indicated, the particular remedy being selected by spe- 
cial symptoms. 

Perversion of sympathetic innervation is shown by 
irregularity in the performance of the vegetative func- 
tions, and by changes in the character of the pulse, 
other than frequency, strength, or feebleness, The 
remedies will be selected, as named in the first part of 
the work. 

The association of the sympathetic with the spinal 
nervous system gives us that condition of disease known 
as spinal irritation. It is of frequent occurrence in 
chronic disease, and when marked is sufficient to pre- 
vent a cure by the ordinary means, being a continued 
source of wrong innervation. It is a little singular 
that the source of this lesion of the spinal cord should 
always be an organ supplied from the sympathetic, and 
that irritation should be so readily propagated back- 
ward along these nerves. Yet it is a fact that a dis- 
ease of irritation can not exist long in an organ with- 
out some disturbance of the great sympathetic, and the 



STUDY OF DIAGNOSIS. 345 

spinal cord immediately behind the ganglion, that fur- 
nish the nervous supply. 

Spinal irritation is usually marked by tenderness on 
pressure over the bodies of the vertebrae, and when 
such tenderness is found, it is taken as evidence of this 
lesion. But once in a while we will find the evidence 
at some distance from the spine, but always in the 
course or termination of the posterior spinal nerves. 

It has been proposed by Prof. John King, to deter- 
mine the locality of chronic visceral disease, by an ex- 
amination of the spine, and this can be done where 
there is spinal irritation. If the reader will refer to a 
text-book on anatomy, he will see that the distribution 
of sympathetic nerves, and connection with the spinal 
cord is very simple. The sympathetic ganglia send off 
large nerves, which before their distribution form a net- 
work, called a plexus, and from this the nerves are dis- 
tributed upon the nearest arteries. Thus if we know 
the source of nerve supply to a plexus; and the distri- 
bution of the arteries nearest to this, we will readily 
make the association between a particular part of the 
spinal-cord, and a special organ or organs. It might 
be remarked that the connection between the cord and 
the ganglia which lie upon the bodies of the vertebra 
in front, is immediately backward and forward by fila- 
ments of communication, and that a limited portion of 
the gray substance of the cord is thus associated in 
action with a ganglion. 

The first cervical ganglion sends its branches upwards 
on the carotids, to supply the brain and the organs of 
special sense; and a nerve downward, which through the 
cardiac plexus is distributed to the heart; thus to a 
certain extent associating the brain and heart in action. 



346 SfUDY OF DIAGNOSIS. 

The other cervical ganglia send nerves downward to 
the cardiac plexus, which supplies the heart, and to 
some extent the lungs. The upper dorsal ganglia 
send off the great splanchnic, which passing through the 
diaphragm form the solar plexus, and from this the 
nerves are distributed upon the cceliac axis to the 
stomach, liver and spleen, and upon the superior me- 
senteric to the small intestine and pancreas. Branches 
from this pass downwards upon the spermatic artery to 
the testes in the male and the ovaries and uterus in the 
female. The lower dorsal ganglia furnish the lesser 
splanchnic nerves, which form above the renal arteries 
the renal plexus, and furnish nervous supply to the 
kidneys, ureters and bladder. The dorsal ganglia fur- 
nish nerves for the formation of the hypogastric plexus, 
which gives nervous supply to the pelvic viscera. The 
sacral ganglia furnish nerves for the sacral plexus, 
which supplies some parts at the outlets of the pelvis, 
and the lower extremities. 

The above is but a brief synopsis of this subject, and 
the reader will do well to give it a thorough study, and 
traceout the distribution of these nerves on an anatom- 
'eal plate. It will be found that there is a free inter- 
communication between different parts, some more 
especially than others, and thus many sympathies ob- 
served in health and disease can be accounted for. 

In the olden time we were in the habit of recom- 
mending the irritating plaster for all these cases, and 
though unpleasant, it may be employed with advantage 
in a great many. It is better, however, to determine 
more exactly the condition of the cord, as quite surely 
it is not always the same. Possibly our old division 
will serve our purpose here, classifying them with refer- 



STUDY OF DIAGNOSIS. 347 

joce to the circulation — a, with vascular excitement; 
b, with enfeebled circulation, or spinal anaemia. 

The case of vascular excitement will be shown in the 
bright eyes and contracted pupils, slight increase of 
temperature, and a pulse that has hardness and undue 
vibration as an element. It is especially the case for 
suppurative counter-irritation over the site of tender- 
ness, though I prefer, as being much pleasanter, the use 
of the wet-pack, of water, vinegar, or water acidulated 
with Sulphurous Acid. The internal remedies will em- 
brace Yeratrum, G-elseminum, Bromide of Potash, and 
these may be aided by means to establish secretion. 

The case of anaemia of the cord will be recognized 
by the dull, sunken eye, feeble circulation to the sur- 
face and extremities, and a pulse that wants strength. 
In many of these cases the skin is relaxed, and there is 
undue exudation. These cases may have the .irritating, 
plaster used to rubefaction, stimulant frictions, rubbing 
of the spine with salt water, the use of electricity 
(Faradization) and means of a similar character. In- 
ternally the remedies will embrace Nux, Ergot, stimu- 
lant doses of Iodine. Pulsatilla, Bromide of Ammonium, 
and if the pulse is small and vibratile, Rhus. 

There are a few cases, marked by a full, sluggish, 
and oppressed pulse, dull eye and dilated pupil, in 
which Belladonna and Ergot will prove very efficient 
internal remedies, and in which a Belladonna plaster is 
the best local application. 



348 STUDY OF DIAGNOSIS. 



NOSOLOGICAL CLASSIFICATION. 

The study of this is beyond the scope of this little 
volume, and the reader is referred to works on the 
" Practice of Medicine," or special treatises on diag- 
nosis, in which this classification is the basis. Our 
stud} T has been wholly with reference to the selection 
of remedies, and the ordinary nomenclature interests 
us only as it points us (o groups of remedies. 

The study of nosology is ot some importance in 
enabling one to give appropriate names, in writing or 
conversing of disease, and especially as satisfying the 
friends of a patient, who are always desirous of having 
a disease named. If the reader will take the classifica- 
tion given, and apply the methods of examination 
named through this work, he will find but little diffi- 
culty. We will pass it in brief review, pointing out the 
method of study, and giving the most pronounced 
symptoms. 



Chlorosis. — In the early menstrual period, usually 
before the age of twenty ; is characterized b} T want of 
blood, impaired nutrition, loss of flesh and strength, and 
differs from anaemia only in a greenish coloration of 
the otherwise blanched and bloodless skin. The name 
has no meaning in selecting remedies, unless in some 
cases, the peculiar shade of green would indicate Cop- 
per, and in others Sulphate of Alumina and Iron. 

Scorbutis — Is caused by a want of vegetable food, 
and is especially marked by softened and spongy gums, 
usually of a deeper color than natural ; and, finally, by 
a tendency to deliquescence in all tissues of low organi- 



STUDY OP DIAGNOSIS. 349 

sation, especially cicatrical tissue. The name indicates 
a special pathological condition, and calls for vegetable 
acids (Citric Acid or lemon juice), and for vegetables, 
especially 'those containing a considerable amount of 
Potash. 

Dropsy — Has different causes, which require special 
stud}'. It is characterized by exudations of water into 
the cellular tissues — oedema, anasarca ; or into the 
serous cavities — ascites, hydrothorax, hydropericardium, 
hydrocephalus, hydrocele, and hydrops articuli. The 
diagnosis is made by the touch, which gives a different 
sensation from growths, deposits, or accumulations of 
pus, blood, or gases. It refers us to special remedies, 
Apocynum, Aralia, and the hydragogue cathartics and 
diuretics for the removal of the accumulated fluid. 

Diabetes Mellitus. — Increased flow of urine, with 
loss of flesh and strength, and impairment of every 
function. Examination of the urine, as named under 
that head, determines the presence of sugar. The name 
does not point to remedies, which must be selected with 
reference to the symptoms in each individual case. 

Pyemia. — A condition of blood simulating suppura- 
tion in solids, usually having its origin in injuries or 
wounds of loose, non-vital tissues, though it may arise 
from wounds of any part in which putreseency develops. 
The condition may be known by the extreme restless- 
ness, and fear of a fatal result, a small, tremulous pulse, 
(sometimes the pulse has its usual inflammatory condi- 
tion until a short time before death), a peculiar con- 
striction of tissue about the base of the brain ; pinched 
nose, and a general expression of irritability. It points 



35C STUDY OF DIAGNOSIS. 

us to antiseptics and good food, as the means of cure. 
Opiates should not be used to relieve pain, if it is pos- 
sible to get along without them. 

Tuberculosis. — The impairment of the blood that 
gives rise to aplastic and cacoplastic deposits, has 
already been described. There is impairment of diges- 
tion, blood-making and nutrition, with loss of flesh 
and strength, local symptoms indicating the situation 
of the deposit. The treatment is suggested by the 
above description — increase retrograde metamorpho- 
sis and excretion, and remove the low albuminoid mate- 
rials, and improve nutrition. 

Fever. — The different forms of fever have been de- 
scribed in a preceding classification, and it is only 
necessary here to call attention to the principal phe- 
nomena, and the treatment. A fever is a disease of 
four stages — forming, cold, hot and sweating. The 
S} T mptoms of the first are of prostration — there is an 
impairment of life. In the second this impairment is 
still greater, especially of innervation and circulation, 
and the patient feels cold. In the third vascular and 
nervous excitement are marked, the pulse is frequent, 
the temperature increased, the secretions partially 
arrested, and the vegetative functions impaired in pro- 
portion to the severity of the disease. In the fourth 
stage, the various functions are restored, and excretion 
established — it is convalescence. Whether a fever lasts 
a day or a month, it has these symptoms, with addi- 
tional ones showing a wrong of the blood. 

The treatment suggested is very plain. In the form- 
ing and cold stages means to increase the life, and espe- 
cially to stimulate the nervous and vascular systems 



STUDY OF DIAGNOSIS. 35l 

In the hot stage, to reduce the frequency of the pulse, 
the temperature and excitation of the nervous system, 
and to increase excretion and the vegetative functions, 
employ such means as will check destruction of the 
blood, or that will neutralize any morbid element in it. 

Local Disease. — Local disease is determined by the 
unpleasant sensations in the part, experienced by the 
patient; by change in its functional expression: and 
by an examination with our senses, and the application 
of any instrumentality that medicine affords. 

The distinction between functional and structural 
disease is determined by the careful examination of the 
physician. In functional disease we expect to find 
little or no change in the physical properties of the 
part; in structural disease such changes will be de- 
tected 

The Brain. — Disease of the brain is shown by un- 
pleasant and painful sensations experienced in the 
organ, a change in the expression of the face and body, 
and changes in its functional expression. The charac- 
ter of the disease will be diagnosed by symptoms 
already pointed out. 

It suggests the use of brain remedies,. in addition to a 
right general treatment. As examples we may name 
G-elseminum, Belladonna, Pulsatilla, Opium, Bromides 
of Potash and Ammonium, Phosphorus, Cypripedium, 
Camphor, Nux, Quinia, Rhus. 

The Spinal Cord. — Disease of the spinal cord is 
shown by unpleasant sensations experienced in the 
spine by the patient, by wrongs of muscular movement, 
respiration, etc. The same remedies are employed as 
for the brain, 



352 STUDY OF DIAGNOSIS. 

Of the Xose. — Unpleasant sensations in and change 
in secretion of the nasal mucous membrane. Remedies 
that influence mucous membranes. 

Pharynx. — Sore throat, with unpleasant sensations 
in deglutition and respiration. The throat can be in- 
sj^ected and changes of structure noted. 

Larynx. — Unpleasant sensations in the part : change 
in the voice: difficulty of respiration ; cough: sputa; 
and change in the sounds on auscultation. Special 
remedies. Aconite. Spongia. Antimony, Collinsonia. 

Bronchia. — Unpleasant sensations in the thorax; 
difficult respiration : cough ; sputa : and change in the 
sounds heard on auscultation — blowing. Treatment 
will be general, and remedies that influence mucous 
membranes. 

Lungs. — Unpleasant sensations in the thorax : diffi- 
cult respiration; cough; sputa; sounds heard in aus- 
cultation — crepitant : percussion gives dullness when 
consolidation has taken place from any cause. Reme- 
dies. Aconite. Ipecac. Lobelia. Drosera, Agrimonia, 
Phosphorus. 

Heart. — Unpleasant sensations in the praecordia ; 
sense of oppression and impending danger : change in 
the pulse ; and impairment of the circulation. Special 
remedies. Teratrum. Aconite, Digitalis. Cactus. Pulsa- 
tilla. Rhus. Bryonia. 

Pleura. — Pains of a sharp, lancinating character 
difficulty in inspiration ; cough ; no change upon aus 
cuhation except in rare cases ; dullness on percussior 
from effusion. Eemedies are ail general, unless we ex 
cept Bryonia and Asclepias. 



STUDY OF DIAGNOSIS. 353 

Mouth and Salivary Glands. — Unpleasant sensa- 
tions, especially on taking food ; on exposure structural 
lesions can be seen and felt. Special remedies, Mer- 
cury, Iris, Podophyllin, Pl^tolacca, Collinsonia. 

(Esophagus. — Difficult deglutition. Eemedies gen- 
eral, except for nervous dysphagia, Pulsatilla. 

Tonsils. — Uneas.v sensations in the throat; difficult 
deglutition and respiration ; can be inspected and 
changes in size and form noted. Eemedies, Aconite, 
Nitrate of Potash. 

Stomach. — Unpleasant sensations in the region of 
the stomach, and impairment of function. Special 
remedies, Hydrocyanic Acid, Bismuth, Muriatic Acid, 
Lactic Acid, Pepsin, Hydrastis, Podophyllin, Leptan- 
drin, Nux, the class of emetics. 

Small Intestine. — Uneasiness in the abdomen; im- 
pairment of digestion ; diarrhoea. Special remedies, 
Bismuth. Podophyllin, Nitric Acid, Hydrastis, Nux, 
Agrimonia, Epilobium, Aconite, Ipecac, a part of the 
class of cathartics. 

Large Intestine. — Uneasiness in the abdomen; 
tormina; tenesmus; and small, non-faecal evacuations. 
Special remedies, Aconite, Ipecac, Aloes, Colocynth, 
Haraamelis, Collinsonia. 

Liver. — Unpleasant sensations in right hypochon- 
drium, with occasional slight change in form and size ; 
impairment of digestion ; and changes in the color of 
the skin. Special remedies, Leptandra, Nux, Nitric 
Acid, Sulphur. 
30 



354 



STUDY OF DIAGNOSIS. 



Spleen. — Unpleasant sensations in left hypochon- 
drium; change in form and position of the organ de- 
termined by the touch ; and impairment of blood-mak- 
ing and nutrition. No special remedy unless it be the 
Uvedalia. 

Peritoneum. — Sharp, lancinating pain in the abdo- 
men, increased by pressure, motion or respiration, with 
small, wiry pulse, if inflammatory. ISTo special reme- 
dies. 

Supra-Renal Capsules. — But one disease known— 
Addison's — characterized by bronzed discoloration of 
the skin, gradually increasing, and associated with im- 
pairment of the vegetative functions. No remedies 
known. 

Kidneys.— Unpleasant sensations in the lumbar re- 
gion near spine, in the urinary apparatus below, and in 
micturition ; changes in the urine determined by ex- 
amination ; and an influence upon the nervous system 
by retained urea — excitation at first, coma following. 
Special remedies, G-elseminum, Belladonna, and the 
class of diuretics. 

Bladder. — Unpleasant sensations behind the pubes; 
perineal pressure; difficult and painful micturition ; and 
the presence of its secretion, mucus or pus, in the 
urine. Special remedies. Eryngium. Apis, Phosphorus, 
Hydrangea, Agrimonia, Staphysagria. 

Prostate G-land. — Unpleasant sensations in the peri- 
neum; difficult and painful micturition ; and an ex- 
amination externally and by rectum determines change 
in size and sensibility. Special remedies, Staphysagria 
Hamamelis, Phosphorus, Pulsatilla. 



STUDY OF DIAGNOSIS. 355 

Urethra. — Unpleasant sensations in passing water, 
discharges. Special remedies, Cannabis Indica, Copai- 
ba, Cubebs, Macrotys, Sandal Wood. 

Testes. — Unpleasant sensations in ; changes in size 
and form. Special remedies. Phytolacca, the Bromides, 
Pulsatilla, Staphysagria, Phosphorus, Iodine. 

Ovaries. — Unpleasant sensations in the iliac regions , 
change of size and sensibility to the touch ; and wrongs 
of the reproductive function. Special remedies, Ma- 
crotys, Actea, Caulophyllum, Pulsatilla. 

Uterus. — Unpleasant sensations in the pelvis ; change 
of size and form ; change of position ; change in the 
menstrual and reproductive functions by the discharges ; 
change in the tissues determined by the touch and by 
night. Special remedies, Ergot, Macrotys, Caulophyl- 
1 u m . 

Vagina and Vulva. — Unpleasant sensations ; by the 
discharges ; and by an examination by the touch and 
speculum. Special remedies, those which influence the 
reproductive function ; other remedies such as influence 
mucous membranes, and the general health. 

Arteries -Changes in the sensation given to the 
touch, and impairment of the circulation. Special 
remedies, the same that influence the heart. 



Veins. — Change in size, form, course, and in their 
color. Special remedies, Hamamelis, Ergot, Iron. 

Lymphatic Glands. — Changes in size, in tempera- 
ture and in sensibility; with special impairment of the 



356 STUDY OP DIAGNOSIS. 

blood, and of nutrition in some cases. Special reme- 
dies, Phytolacca, Iris, Stillingia, Alnus, Scrophularia, 
Iodine, Bromine, Phosphorus, Arsenic. 

Skin. — Unpleasant sensations ; changes in structure 
determined b.y examination. Special remedies, diapho- 
retics, Arsenic, Phosphorus, Sulphur. 

Eye. — Unpleasant sensations; wrongs of function. 
Special remedies, Belladonna, Calabar Bean, Gl-elsemi- 
num, Opium, Ehus, Macrotys, Cannabis Indica, Arsenic. 

Ear. — Unpleasant sensations ; wrongs of function. 
No special remedies. 

Bones. — Unpleasant sensations ; change of form, size, 
sensibility, and impaired use. No special remedies. 

Muscular Tissues. — Unpleasant sensations in move- 
ment ; changes in size, form and sensibility. Special 
remedies, Macrotys, Apocynum, Bryonia, Sticta, Phyto- 
lacca, Colchicum, Potassse. 

Articulations. — Unpleasant sensations ; changes in 
form, size and sensibility. No special remedies, except 
possibly Bryonia and Macrotys. 

Cellular Tissue. — Symptoms of inflammation, sup- 
puration. Special remedy, Lime. 

We have passed most of the organs and tissues in 
review, in order to impress the fact that remedies do 
act on special parts. Only a few remedies have been 
named as examples, but the reader is advised to make 
notes of remedies under the various heads as they come 
to his notice by reading or experiment. It must prove 



STUDY OF DIAGNOSIS. 357 

of value in therapeutics, to be able to at once associate a 
group of remedies with special parts and functions, as hav- 
ing them thus clearly before us we can better choose the 
individual remedy applicable to the case in hand. 

Much more might have been written on this subject, and 
I doubt not the reader will feel that a more minute exam- 
ination of local disease would have been profitable. Yet 
there are many authorities who give this information, and 
as said before, it is beyond the scope of our work to make 
this study. 

Something must be left for each reader to think out for 
himself, (and this is really the most profitable study), and 
I have endeavored to point out the way, and give subjects 
for such thought. The physician who does his own think- 
ing will always have the largest measure of success, and 
the greatest pleasure in and from his work. 



INDEX OF REMEDIES 



In appending- an index of remedies, I desire to point out the 
prominent indications for their use, whilst reference is made tc 
the pages where the agents are noticed. With some of the agents 
this index will be quite a complete study, and as the reader has 
all the special indications before him, he will be better able to 
group them together. So in the study of individual remedies, 
I tnought it would be better to so arrange the index that the 
reader might do his reading with reference to the one agent; or 
when using it as a work of reference, he would be pointed to the 
special feature he desired to study. 

Acids, Indicated by deep redness of tongue and other parts 

freely supplied with blood, 80, 81, 102 

Slick tongue 103 

In stomachic digestion 271 

Acid Acetic, Indicated by deep redness, zymosis 81, 102 

Lactic, Indicated by deep redness 81 

Tissues pinched and stringy 143 

Eructations from stomach 112 

Sepsis Ill 

Gastric digestion 272 

In diseases of the stomach 353 

Muriatic, Contraction of tissues 65 

Deep redness of mucous membranes 81 

" and condition of stomach 102 

Slick tongue 103 



360 STUDY OF DIAGNOSIS. 

Acid, Muriatic, Sepsis Ill 

Eructations from stomach 112 

Hot breath, pungent 199 

As an epidemic remedy 221, 227 

Typhoid symptoms 238 

Pungent heat 263 

Gastric digestion. 272 

In diseases of the stomach 353 

Nitric, Irritation of sympathetic 65 

Violet color 82, 103 

To influence the temperature 166 

As an epidemic remedy 229 

Whooping cough 230 

To influence the pancreas , 293 

Sulphurous, Color muddy or dirty 83 

Erysipelatous redness, blanched 90 

Dirty tongue 104 

Increased secretion of saliva Ill 

Large pulse, empty 153 

Mawkish odor from excreta 198 

" " breath 199 

As an epidemic remedy 227 

Zymosis 231 

Typhoid symptoms 238 

Pungent heat 273 

Aconite, Illustrating the certainty of medicine 15 

Inflammation of brain 62 

Effusion, with bright eyes 63 

Constriction about temples 65 

Shrunken face 66 

Simple increase of color , 78 

Vascular excitement 79 

Constriction and thinning of structures 84 

Elongated and pointed tongue... 95 

Contraction of tongue 106 

Eructations from stomach 112 

Contraction and irritability of muscular tissue 142 

Small pulse .* 153 



INDEX. 



361 



A.conite, Epidemic remedy 22? 

To influence the nerve centers 26. 

Tongue, redness of tip and edges 269 

Contracted slick tongue 272 

To infinence the pancreas 293 

To influence secretion 299 

To influence the kidneys 304 

Frequency of pulse 31' 

Determination of blood 322 

Congestion 323 

In inflammation 328 

To influence sympathetic innervation 344 

In diseases of the larynx, lungs and heart 352 

In diseases of the stomach and intestinal canal 353 

Acetate of Potash, Sensation of fullness without elasticity... 143 
To remove bile pigment 290 

Alkaline Salts, Pallid tongue 101 

Acidity of stomach 211 

Potash, Muscular wrongs 102 

Alcoholic Stimulants, Oppressed voice, hollow and unsteady, 174 
Small, soft pulse 153 

Asclepias, Kubeola, measles 229 

Apis, Surface hot, burning, painful, dry 231 

In disease of the bladder 354 

Aralia, A remedy for dropsy 349 

Ammonia, Enfeebled capillary circulation 79 

Scarlatina 229 

As an antidote 247 

As a cerebral stimulant 337 

Actea, Pinkish color 86 

. In the treatment of disease of the ovaries 355 

Arsenic, White line around mouth, dragging down of corners, 85 

Tongue large, thick in center, incurved edges 103 

Dull and opaque skin „ 93 

Increased secretion of saliva Ill 

Pinched, contracted tissues 144 

Open, tremulous pulse 154 

Feebleness of voice 174 

31 



362 



STUDY OF DIAGNOSIS. 



Arsenic, Influence upon the temperature 

Defect in excretion from the lungs 

Anaemia of the spinal cord 

In the treatment of diseases of the skin 

Alnus, In disease of the lymphatic glands 

Apocynum, Fullness of eyes, fullness of face, drawing down 
of corners of mouth 

Dull eyes and relaxation of face 

Full eyelids ' 66 

Full pulse, doughy, accompanied by muscular pain... 

(Edema of cellular tissue 

Defect in excretion from the lungs 

To increase excretion from bowels 

A remedy for drop-y 

In diseases of muscular tissue 

Asclepias, In disease of the pleura 

Agrimonia, In diseases of the respiratory apparatus 

In diseases of the gastro-intestinal canal 

In diseases of the kidneys ... 

Aloes, To influence the large intestine 

Baptisia, Deep color, purplish, brown, b'ack 

" sepsis 

Saliva, viscosity of 

Full pulse, oppressed 

Pungent heat 

Fetor of cynanche 

An epidemic remedy 

Typhoid symptoms 

Pungent heat, sepeis 

Belladonna, Dull eyes, dilated pupils 

Dull, sodden expression of face .". 

Expressionless eyes 

Slow return of capillary circulation when pressure is 
made upon the skin 

Dull, colorless eye 

Fullness of tongue 

Full, oppressed pulse 

To influence the temperature 166, 



26i 

297 
339 
356 
356 

62 
63 
,34 
153 
155 
297 
307 
349 
356 
352 
352 
353 
354 
353 
82 
103 
111 
153 
165 
199 
227 
238 
263 
62 
63 
66 

79 

87 

106 

153 



INDEX. 363 

Feebleness of voic? . 174 

Spasmodic cough 179 

Pain in head, heavy, dull, sleepy 203 

Pain dull, heavy, full, with sense of functional im- 
pairment 206 

An epidemic remedy 227 

Scarlatina 229 

In convulsions 231 

To influence the skin 299' 

To influence the kidnej^s 304 

To influence the circulation 317 

A remedy for congestion 323 

Feeble cerebral circulation 337 

In the treatment of paralysis , 343 

In disease of the brain 351 

In disease of the kidneys... 354 

In disease of the eye 356 

Bismuth, Dragging down of corners of mouth 85 

Elongated and pointed tongue 95 

Eructations, pyrosis 112 

Irritation of stomach, 269 

Excess of gastric juice 271 

Intestinal dyspepsia 272 

To influence the pancreas 293 

In diseases of the stomach and small intestine 353 

Bitter Tonics, Eelaxation of tissue 143 

Defect in electricity 265 

Absurdity in prescription 267 

Want of expression 270 

Intestinal atony 273 

Want of appetite 277 

Bryonia, Constricted tissues 65 

Eight eyebrow drawn down, flushed right cheek 6Q 

Pain, excited circulation 69 

Deep flush of right cheek 86 

Venous obstruction 7S 

Sharp stroke of pulse, even vibratile current 154 

To lessen tne temperature = 166 



364. STUDY OF DIAGNOSIS. 

Bryonia, Cough points at supra-stern al'notch 178 

Pain in right side of head, passing from before back- 
ward 203 

Pain, with sense of oppression 205 

An epidemic remedy 221, 227 

Excess of temperature 260 

"Wrong in combustion 261 

To influence excretion from the lungs 297 

To influence excretion from the skin 299 

In the treatment of inflammation 329 

In diseases of the respiratory apparatus 352 

In diseases of the articulations 356 

Beeberina, Brownish discoloration of skin 92 

Bromides, Scanty secretion of saliva 110 

In diseases of the testes 355 

To influence the lymphatic glands 356 

Bromide of Ammonium, Sudden cry, with sobbing respira- 
tion 175 

Spasmodic cough 179 

In diseased the spinal cord 340 

In the treatment of paralysis 343 

In the treatment of spinal irritation 347 

In diseases of the brain 351 

Bromide of Potash, A remedy in delirium tremens 332 

In spinal irritation 347 

In disease of the brain 351 

Carbolic Acid, Blanched appearance in inflammation 90 

Dark coating of tongue 104 

Fetor of putrescence ]98 

Camphor, In disease of the brain 351 

In delirium tremens 332 

Caulophyllum, In disease of the ovaries 355 

Cactus, Precordial oppression 82 

Irregularity of pulse, wrong of stroke 154 

■Cough pointing at supra-sternal notch 178 

Morbid sounds from the heart 195 

To influence the temperature ,... 261 

To influence the pancreas 291 



INUEX dbO 

Cactus, To influence the skui 297 

In diseases of the heart «... ■ 352 

Canabis Indica, In diseases of the urethra, 355 

In diseases of the eye ^ 356 

Calabar Bean, To influence the eyes. ,. 356 

Capsicum, Want of power in pulse 153 

Cold feet 169, 263 

In the treatment of delirium tremens 332 

Chloroform, to relieve irritation of the sympathetic nervous 

system 65 

Precordial oppression 82 

Elongated, pointed tongue. 106 

In the treatment of convulsions , ... 340 

Chloral, In the treatment of delirium tremens 332 

Cathartics, Stimulant. Congestion of brain 62 

Hydragogue, Effusion into brain 63 

Full, broad tongue 95 

Heavily loaded tongue 99 

Creasote, In scarlet fever 229 

Ohloride of Sodium, Blueness with pallor. 82 

Increased secretion of saliva Ill 

In scarlet fever. 229 

Colocynth, To influence the large intestine 353 

Chlorate of Potash, Appearance of tongue 104 

Increased secretion of saliva , Ill 

Sepsis 165 

Odor resembling lochial discharge 199 

An epidemic remedy 227 

In puerperal fever 231 

Typhoid symptoms , 238 

Pungent heat 263 

Chlorine, Odor of putrescence 19S 

Chlorinated Soda, In puerperal fever 231 

Cod-liver Oil, Pinched, stringy tissues 144 

Want of calorifacient food 169 

Feebleness of voice 174 

To influence the temperature 261 

In defective sympathetic innervation 344 



^™ 



366 STUDY OF DIAGNOSIS. 

Chloride of Lime, As a disinnV.lant 198 

Cider, Deep red tongue, dry, contracted, with dark sordes... 102 

Collinsonia. In diseases of the larynx 352 

Influences the large intestine and rectum 353 

Chelidonium, Color dull and opaque 92 

Dull, heavy, tensive pain, with occasional twinges, as 

if the part was being torn 106 

Dull, leaden, yellow fur 100 

Intestinal dyspepsia 273 

A pancreatic medicine 292 

Ciiamomilla, Gastric indigestion 270 

Intestinal indigestion 272 

Charcoal. Excess of gastric juice 271 

Columbo, Atony of stomach 270 

Copper, Sallowness with a tinge of green 92 

Dull, cheesy-looking fur with tinge of green 101 

An epidemic remedy 222, 223 

As a restorative 274 

Greenish pallor of skin 277 

In Chlorosis 348 

Colchicum, In disease of muscular and fibrous tissue 356 

Cupping, Congestion of brain 62 

Effusion into brain 63 

Cypripedium, In the treatment of diseases of the brain 351 

Digitalis, Fullness of the tissues of the face 65 

Dull, leaden color 82 

Pulse, want of power in impulse 153 

To influence the temperature.- 261 

Erequent pulse 317 

Change in the character of the pulse 318 

To influence the sympathetic nervous system 344 

Drosera, Spasmodic cough .- 179 

Whooping cough 22 

Measles, 229 

To influence excretion from the lungs ... ...... 297 

In diseases of the respiratory apparatus 352 

Emetics, Heavily loaded tongue at base 99, 271 

^recthites, In excessive secretion from skin 299 



INDEX. 367 

Erigeron, Passive hemorrhage 115 

To influence secretion from the skin 299 

Ergot, Fullness of eyes, face, prominent veins 62 

Passive hemorrhage 115 

Feeble voice, sighing respiration 174 

A remed} 7 for congestion 304 

Slowness of pulse 318 

In the treatment of paralysis. 343 

In disease of the spinal cord 347 

To influence the uterus — 355 

Electricity, To influence the temperature 261 

Epilohium, Intestinal irritation 272 

In disease of the gastro-intestinal canal 353 

Eryngium, Irritation of the bladder 322 

In disease of the bladder 354 

Gentian, Loss of appetite, 270 

Gelseminum, Bright eyes, contracted pupils, flushed face 61 

Inflammation of brain 62 

Pain, with evidence of excitation 69 

.Restlessness, with determination of blood 71 

Vascular excitement... 79 

Elongated and pointed tongue 106 

Pinehed, contracted tissues 142 

Full pulse, vibratile 153 

To influence the temperature ..166, 260 

Sudden, shrill, sharp cry 175 

Pain, sharp, restless 203 

Exalted sensibility, arterial throbbing., 206 

An epidemic remedy 227 

To influence the skin 299 

In jaundice 290 

In irritation of the kidneys 304 

Frequent pulse 317 

In the treatment of delirium 331 

" mania 333 

" convulsions 340 

" paralysis • 342 

" delirium tremens 332 



368 STUDY OF DIAGNOSIS. 

Gelsenmmm, Determination of blood 322 

In hyperaemia of the spinal cord 339 

In suppression of urine 341 

To influence the sympathetic 347 

Gallic Acid, Passive hemorrhage 1.5 

Helonias, Pinkish color of surface 86 

Hydrastis. Yellow coating of tongue IOC 

Intestinal dyspepsia Ill 

Eructations feebly acid 112 

Indigestion 269 

Tongue full and expressionless 270 

In disease of the stomach 353 

In delirium tremens 332 

Hamamelis. Swollen, relaxed eyelids 84 

Color purplish from venous stasis 89 

In diseases of the large intestine 353 

" urinary apparatus 354 

" venous system 355 

Hydrangea, In diseases of the bladder 344 

Hypophosphites, Pinkish color of surface 86 

Dull, leaden color of tongue 103 

Tissues loose and flaccid 143 

Feebleness of voice 174 

To influence the temperature 261 

Hydrocyanic Acid, Elongated and pointed tongue, reddened 

tip and edges 95 

Acid eructations 112 

Gastro-intestinal irritation 269 

In diseases of the gatro-intestinal canal 353 

Iodides. Scanty secretion of saliva 110 

Iodide of Ammonium, Tissues pinched and contracted 144 

Localized pain 206 

Iodide of Potassium. Fullness without elasticity 143 

Xot when tissues are pinched or stringy 144 

Iodine, As a disinfectant 198 

To influence the pancreas 292 

In the treatment of delirium tremens 332 

A stimulant to the sympathetic ... 347 



INDEX. 369 

Iodine, To influence the lymphatic system 356 

Iron, Muriate of, To influence the skin 300 

In the treatment of inflammation 329 

Solid blue color 82 

Eyelids full, swollen 84 

Blueness of veins 87 

Tissues loose and flaccid 143 

Feebleness of voice 174 

Pain in the back of head, dull, heavy 203 

An epidemic remedy 222, 223 

In zymotic disease 231 

An endemic remedy 239 

Defect in electricity 265 

As a restorative 273 

Want of color. 274 

Anaemia ' 310 

Anaemia of the spinal cord 339 

Deficient sympathetic innervation 344 

In chlorosis 348 

In wrongs of the venous circulation 355 

Muriated Tincture, Blueness with deep color of tongue 87 
" " Deep erysipelatous redness 90 

Iris, Scanty secretion of SaHva 110 

Enlarged thyroid gland 

In disease of the lymphatic system 356 

Ipecac, Excess of color , « 79 

White line around mouth with thinning of tissue 81 

Elongated and pointed tongue 95 

Acid eructations 112 

Opaque mucus 1 14 

Active hemorrhage 115 

To relieve irritation of stomach 269 

Pinched face... '. 272 

To influence the pancreas 2 l J3 

To influence the skin 299 

Irritation of the bowels 322 

In disease of the respiratory apparatus 352 

In disease of the gastro-intestinal canal 353 



370 



STUDY OP DIAGNOSIS. 



Lobelia, General bluish or purplish color from venous ob- 
struction ; 89 

Fullness of eyes and face 62 

Want of sympathetic innervation 65 

Capillary stasis from venous obstruction 79 

Precordial oppression and constriction of the chest... 82 

Fullness of tongue 106 

Full and doughy tissues 142 

Pulse full and doughy , 153, 155 

Halting voice 174 

Oppressed voice 175 

Yielding or tremulous character of sounds from the 

chest 189 

Anguish, fear of impending danger 204 

An epidemic remedy 227 

In measles '2 29 

To influence the temperature 260 

Defective excretion from the lungs 297 

To influence the skin 299 

To influence the circulation 317 

Slowness of pulse 318 

Congestion 323 

In disease of the respiratory apparatus 352 

In the treatment of convulsions 340 

Lime, As a restorative 2 73 

In disease of cellular tissue 275. 356 

In lesions of nutrition 314 

Lycopus, To influence the temperature 261 

" '" " respiratory function 297 

" " " shin 299 

Macrotys, Pain from an excited circulation 69 

Deep color under the eyes ?4 

Contraction and irritability with pain 142 

Steady vibratiie pulse without wave 154 

With Rhus 205 

Continued succession of tensive pains 203 

In determination of blood to the uterus 322 

In the treatment of inflammation 329 



INDEX. 371 

Macrotys, In diseases of the reproductive apparatus 355 

In diseases of muscular and fibrous tissues 356 

Nux Vomica, Illustrating the action of medicine 15 

Full, expressionless eyes and face G5 

Expressionless mouth 67 

Pain with enfeebled circulation , 69 

Unsteady movement, anxious countenance 72 

Brownish-yellow coloration 92 

Yellow coating of tongue 100 

Fullness of tongue, 106 

Increased secretion of saliva. Ill 

Influences the temperature. 166 

Pain pointing at umbilicus 203, 205 

An epidemic remedy , 227 

Defect of electricity 265 

Atony of stomach 270 

Atony of intestine 273 

To influence the pancreas 292 

To influence excretion from the lungs. s 297 

In congestion 323 

In the treatment of delirium tremens 332 

To influence the brain 337 

To influence the spinal cord 338 

In anaemia of the spinal cord 339, 347 

In the treatment of convulsions 341 

In the treatment of paralysis 343 

In diseases of the brain 351 

In diseases of the gastro-intestinal canal 353 

Nitric Acid, (See Acids,) Violet color 82, 103 

Nitrate of Soda, An epidemic remedy 222, 223 

Opium, Pain with evidence of atony 69 

Moisture of tongue 105 

Small pulse, open, square wave 153 

Pulse soft and open 154 

In delirium tremens 332 

To influence the brain 351 

Oxide of zinc, Gastric irritation 269 

A pancreatic remedy 292 






372 STUDY OF DIAGNOSIS. 

Panax, Scanty secretion of saliva 110 

To influence the pancreas 292 

Peach bark, Amygdalus, elongated and pointed tongue, red- 
dened tip and edges 95 

Irritation of stomach 269 270 

Intestinal irritation 272 

To improve digestion 293 

Permanganate of Potash, Erysipelatous redness, blanched... 90 
Cadaverous fetor 198 

Phosphorus, Full, pallid face, waving alas nasi 65 

Unsteady movement 71 

Eyelids full, swollen, expressionless 84 

Pinkish color 86 

Dull and opaque skin 93 

Dull, leaden color of tongue , 103 

Moist mouth — Ill 

Feebleness of voice 174 

To influence the temperature 261 

Deficient electricity 265 

As a restorative , 273 

"Want of expression 274 

To influence excretion from the lungs , 297 

Anaemia 310 

Bad blood 314 

To influence sympathetic innervation 344 

In disease of the brain 351 

In disease of the respiratory apparatus 352 

In disease of the urinary and reproductive organs 354 

In diseases of the skin 356 

Phosphate of Soda, Secretions of the mouth neutral or acid.. 112 

Phosphoric Acid, Tissues pinched and stringy 143 

Potash, As a restorative 273 

Pallor of mucous membranes, impairment of muscular 

power 276 

In anaemia 310 

Bad blood 314 

In the treatment of scorbutis 349 

In disease of muscular tissue 356 



INDEX. 373 

Polygonum, To influence excretion by the skin 299 

Phytolacca, Scanty saliva 110 

Pulse, dull stroke with tremulous wave 154 

Mammary inflammation 330 

In diseases ot the mouth and salivary glands 353 

In disease of the testes 355 

In disease of muscular tissue 356 

Pepsine, Enfeebled digestion 272 

In disease of the stomach 353 

Podophyllin, Illustrating the action of medicine 15 

Fullness of the tissues of the face 65 

Cellular tissue full, veins prominent 66 

Full upper lip, pallor 67 

Venous obstruction 79 

Fullness of tissue 84 

Change in pigment, liver spots 92 

Yellow coat of tongue 100 

Fullness of tongue 106 

Moist mouth , Ill 

Full, open pulse 153 

Contra-indicated when pulse is small and wiry..... 154 

Pain in ischiatic notches 203 

An epidemic remedy 221, 227 

An endemic remedy 239 

Dull, expressionless face 270 

Deficiency of gastric juice 271 

Intestinal atony 273 

To influence the pancreas 292 

To increase intestinal secretion 293 

To increase excretion by the bowels 307 

In diseases of the gastro-intestinal canal 353 

Pulsatilla, Color dull purple 82 

Eyes sunken, contracted 84 

Sudden dropping of wave of blood as it passes the 

finger 154 

Cough points at supra-sternal notch 178 

Mental rest 195 

Pain, sharp, limited in location, despondent 203 



374 STUDY OF DIAGNOSIS. 

Pulsatilla, To influence the sympathetic nervous system 344 

To influence the brain 351 

To influence the heart 352 

In dysphagia 353 

To influence the reproductive organs.. 354, 355 

Quinine, Full, expressionless face.. 65 

Drooping tissues, expression sad 69 

Unsteady movement, relaxation of muscles 72 

Causes dryness of tongue 4 105 

Moist mouth 1 n 

Tissues loose and flaccid 143 

Soft pulse 153 

Contra-indicated by hard and wiry pulse 154 

Feebleness of voice 174 

Tremulous sounds from chest 18S 

An epidemic remedy..., 227 

Periodicity 235, 236, 237 

Malaria 246 

A. nervous stimulant 265 

To influence the brain 331, 351 

In delirium tremens 332 

As a remedy for pain 337 

To influence the spinal cord 339 

Rhubarb, Elongated and pointed tongue, gastric irritation... 95 

Acid eructations 112 

Irritation of gastro-intestinal canal 269 

Restoratives, "Want of expression . 54 

To increase the blood 273 

Rest, Expression of 54 

Rhus, Constriction about temples and eyes 65 

Pinched eyes 66 

Pain with excitement of circulation 69 

Bright flush of left cheek 85 

Bright redness of surface 90 

Eroded appearance of anterior papillae of the tongue, 107 

To influence the temperature 166 

Sharp cry, cry encephalique <• 175 

Frontal pain, pain in left orbit 203 



INDEX. 375 

Rhus, Burning pain 205 

An epidemic remedy 22] 

Zymosis ■ 231 

An endemic remedy 239 

Illustrating prescription from single symptoms 255 

To influence the temperature 260, 201 

Pungent heat 2.63 

To influence the skin 300 

In the treatment of inflammation 329 

" delirium 331 

" spinal irritation 347 

To influence the brain 351 

In diseases of the heart , .... 352 

< ; eye 356 

Santonine, White line around the mouth with fullness of 

tissues 84 

Sighing respiration 174 

Full upper lip, picking at the nose 67 

Staphysagri;), Full, swollen eyelids 84 

In disease of the reproductive apparatus 354 

Senega, To influence excretion by the skin 299 

Strychnia, Sighing respiration 174 

Fullness of tongue ., 106 

Atony of gastro-intcstinal canal.. 270 

To influence the spinal cord 338, 339 

Serpentaria, to influence excretion by the skin 299 

Stramonium, Constrictive pain, muscular contraction 206 

Sticta, To influence excretion by the lungs 297 

In diseases of muscular and fibrous tissues 356 

Sulphur, Want of pigment, change of color 93 

Moist, dirty tongue Ill 

As an antiseptic or disinfectant 198 

To influence the temperature 261 

Change of pigment 276 

In hypergemia of the spinal cord 339 

To influence sympathetic innervation 344 

In disease of the liver . ... 353 

« skin 356 



376 



STUDY OP DIAGNOSIS. 



Solanurn, Congestion of the kidneys 304 

Sinapis Alba, Atony of stomach 270 

Sulphite of Soda. Erysipelatous redness 90 

Pallor of tongue, with dirty coat 83 

Dirty tongue 104 

Viscidity of saliva Ill 

Large, empty pulse 153 

To influence the temperature '. 165 

Mawkish or sweetish odor 199 

An epidemic remedy 227 

Zymosis 231 

Typhoid symptoms 238 

Heavily coated tongue 271 

Sulphurous Acid, (see Acid Sulphurous.) 

Sulphite of Magnesia, Dirty tongue, redness natural 104 

Sedatives, Dryness of tongue 105 

Silica, Dullness of epithelium, desquamation 276 

Soda, An epidemic remedy 227 

Asa restorative 275 

Anaemia ... 310 

Bud blood 314 

Trifolium Pratense, Paroxysmal, spasmodic cough 230 

Veratrum, Inflammation of brain 62 

In disease of atony 65 

Color, simple excess of. 78 

In disease of thoracic organs 79 

Bright redness, arterial throbbing 90 

Elongated and pointed tongue, evidencing vascular 

excitement in the brain 106 

Glairy, tenacious mucus 113 

Active hemorrhage 115 

Or Aconite 142 

Tissues pinched and stringy , 144 

Full pulse, with strength 152 

Influence of large dose 163 

Cough 178 

227 

231 



An epidemic remedy 
Zymosis 



INDEX. 377 

Veratrum, An endemic remedy , 239 

To influence the temperature 261 

A pancreatic medicine 292 

To increase excretion from the lungs 296, 297 

To influence excretion by the skin 299 

Frequency of pulse 317 

In determination of blood 322 

A remedy for inflammation 328 

Tn the treatment of delirium tremens 332 

Hyperemia of the spinal cord 339 

In the treatment of convulsions 340 

spinal irritation 347 

In diseases of the respiratory apparatus 352 

Wet Sheet Pack, In simple increase of temperature ,. 167 

32 



IHSTDEX. 



Abdomen, pain in 69 

Acid? as remedies 81 

Adventitious sounds 193 

jEgophor.y 192 

A toray applied 19 

Animals. Study of 5C 

Anaemia 31C 

Applied anatomy 19 

Apoplectic condition of brain 62 

Appearance sickly 76 

Arteries 355 

Articulations 356 

Areola S3 

Atrophic irritation 63 

Auscultation 184 

Stethoscope 154 

Healthy sounds in chest. 18c 

Study in English 186 

Physics of 186 

Morbid sounds 186 

Blowing sounds 187 

Blowing and moist 188 

Trem ulous sound 1 5 9 

Sounds from cavities ....190 

Small 190 

Dry 190 

Crepitant sounds 191 

Broncophony 192 

^Egophony ■ 192 

Pectoriloquy 192 

Of the heart 193 

Adventitious sounds 193 

Of the fcptal heart 195, 



Bath in temperature 167 

Basis for all school 25( 

Blood, condition of the 66 

Color from the 77 

Blueness of..... 82, 115. 308 

Puke waves 149 

Wave, length of ...150 

Circulation of the 244 

Condition of the 244 

Making 273 

ExeessVf 308 

Defect 310 

Bad 311 

Evidences of. 313 

Sepsis of 312 

Exudates from 312 

Circulation of 315 

Irregular distribution of318 

Determination of ...320 

Evidences of determina- 
tion of 321 

Examination of 112 

Black vomit 113 

Blowing: sounds 187 

Bladder 354 

Boquer 4." 

Books, advantage of 23 

Bowels 135 

Body thermometer 156 

Bowe's. liver, percussion of..l83 

Excretion from the 3<"'6 

Bones 356 

Brain, condition of the 61 



INDEX. 



379 



Brain, Congestion 61 

Determination of blood. 61 

Apoplectic condition 62 

Inflammation 62 

Effusion 63 

Nutrition 63 

Softening 63 

Atrophic irritation 63 

Functional activity 64 

Innervation from.. 250, 330 
Pain, condition of. ..337, 351 

Brown color 91 

Broad and full tongue 95 

Broad and pallid tongue 101 

Brown and black fur 104 

Broncophony 192 

Cadaverous faeces 138 

Capsules, Supra-ren ai 354 

Cardiac wrongs, Color from. 89 

Cavities, Sounds from 190 

Certainty 24 

Cerebro-spinal meningitis... 232 

Cells, Secreting 283 

Cerumen '295 

Cellular tissues 356 

Children, Better diagnosis 

with 30 

Childbirth, Expression in 59 

Change of form of tongue .. 94 

Cheesy sputa 114 

Changes of kind of tempera- 
ture 170 

Chest, Healthy sounds from..l85 
Chronic disease, Epidemic 

influence in 223 

Change of type in disease 224 

Chicken-pox, Varicella 229 

Cholera 232 

Character of normal secre- 
tion from skin.., 301 

Changes in the character of 

the pulse. 318 

Chlorosis ...348 

Clay-colored faeces 137 

Clinical examination urine. ..130 

Cleanliness., 197 

Classification, general. ..217, 220 



Classification, nosological.. ..348 
Condition of the sympa- 

thetics 65 

Condition of the blood 66 

Convulsions, symptoms of... 74 

Color of the surface 75 

From the blood 77 

Of health 77 

Of mucous membranes.. 77 

Pigment of health 77 

Transparency and clear- 
ness 78 

Excess of 78 

Capillary circulation.... 79 

Eft'acement of. 79 

Venous obstruction 79 

Defect of 80 

Deepening of 80 

Dark red." 80 

Typhoid 80 

Unyielding 81 

An evidence of sepsis... 80 

Deep redness 81 

Acids as remedies 81 

Dull purple 81 

Blueness 82 

Violet 82 

Deep purplish brown... 82 

Muddy 82 

Local 83 

Of the areola of the 

nipple 83 

Under the eyes 83 

Of conjunctiva 87 

Of bright fed 87 

Of deep red 88 

Of purplish 88 

From cardiac wrong 89 

Erysipelatous redness... 89 

Pigment 90 

" Excess 90 

" Transparent.... 90 

" Local excess.... 91 

" Deep 91 

" Brown 91 

" Greenish yello\v92 

" Dull & opaque. 92 

" Bright } r ellow.. 92 



380 



STUDY OF DIAGNOSIS. 



Color, pigment, greenish 92 

" Tallow-like 92 

" Dirty 93 

" Want of 93 

Of faeces 137 

Coatings of tongue 97 

Yellow , 100 

Dark 104 

Contraction of tongue 106 

Cough 176 

Expresses irritation 176 

Dry, ringing 177 

Forcible 177 

Strength 177 

Short, sharp, hacking... 178 

Points .....178 

Spasmodic „ 179 

Contagious diseases 227 

Condition of the blood 245 

Of the tissues 278 

Of the kidneys 303 

Constipation 137, 3u6 

Congestion 61, 320 

Evidence of.. 321 

Convulsions 339 

Intrinsic 340 

Extrinsic 341 

Cord, spinal 351 

Cry of pain 43 

Encephalique 175 

Cu'tivation of the senses 38 

Dark red color 80 

Dark coatings 104 

Dark brown faeces 137 

Dead, awake, asleep 25 

Development of senses by 

use 34 

Decumbence 53 

Depression or excitation 55 

Determination, expression of 69 
Degeneration, expression of.. 70 

Defect uf color 80 

Deepening of color. 80 

Deep redness, associated with 

asthenia 81 

Deep purplish brown 82 

Deep color 91 



Dessicated mucus , ,114 

Deposits, urinary 129 

Tabic of urinary 134 

Deficient faeces 136 

Deposits 279 

Degeneration 280 

Defect in secretion 299 

In excretion from lungs,297 

Of the blood 310 

Determination of blood 320 

Delirium 331 

Delirium tremens 331 

Diagnosis, study of 9 

Anatomy necessary in ... 20 

Methods of 28 

Better with children 30 

Use of the senses in 48 

By the eye 49 

By the touch 139 

by the ear .171 

Physical 179 

Disease not an entity 12 

Expressions of. 14 

Relation between reme- 
dies and 15 

Varieties of color in.. „... 42 

Evidence of local 58 

Local 66 

Range of temperature in 159 
Temperature in chronic 160 

Cause of 165 

Voice expresses 173 

Laryngeal,voice changed 

by 176 

Diseases, classification of 21 1 

Contagious 227 

Change of type in 224 

Disuse, senses lost by 35 

Dirty color .". 93 

Dirty fur 103 

Discharges, examination of. 108 

Disinfection 198 

Distinction and definition of 

disease 209 

Digestion, intestinal 272 

Distribution of blood irreg- 
ular 318 

Diabetes 349 



INDEX. 



381 



Doctrine of Rademacher 222 

Dryness of tongue 105 

Dry, ringing cough 177 

Dropsy 349 

Dull purple color 81 

Dull and opaque color 92 

Dull, elastic stroke of pulse.. 1 50 
Dullness on percussion 181 

Ear ...356 

Education of the senses 32 

Educated nose 45, 196 

Effusion 63 

Effort for rest 71 

Effa cement of color 79 

Elongated & pointed tongue 

95, 106 

Elements of disease, first 13 

Empty pulse 151 

Emotion 334 

Entity, disease not an 12 

Encephalique cry 175 

English, study of ausculta- 
tion in 186 

Equalizing the circulation. ..319 

Errors from nosology 9 

Eructations, examination of.M2 

Expression of the mouth 67 

Provokes function 68 

Of disease 14 

In the Horse 51 

Law of. 57 

In the face 58 

In Childbirth 58 

Facial 60 

Of determination 69 

In motion 70 

Of degeneration 70 

Of the voice 172 

Expresses disease 173 

Examination of tongue 93 

Of the discharges 108 

Discharges from nose.... 109 
Discharges from mouth..H0 

Saliva increased 110 

Saliva, reaction of Ill 

Of discharges from the 
stomach 112 



Examination of blood 112 

Eructations 112 

Vomiting 112 

Black Vomit 113 

Of discharges from res- 
piratory tract.... 113 

Mucus, thin, glairy 113 

M ucus opaque 113 

Globular sputa 114 

Cheesy sputa 114 

Dessicated mucus .14 

Pus 114 

Blood 115 

Mucus streaked with 

blood 115 

Exudative material 116 

Of the .urine 116 

Objects of. 118 

Clinical of urine 130 

Of the sediment 132 

Of the feces 135 

Care in 202 

Of the urine 301 

Excess of the urine 304 

Of the excretions from 

the bowels 306 

Of blood... 308 

Of color pigment 90 

Of color pigment local.. 91 

In secretion from skin. ..298 

Exaggeration by the sick.... 29 

By the nurse 29 

Excitation or depression 55 

Extension, flexion 73 

Excretions, odor of 199 

Prom lungs, defect in... 29 7 

From the bowels 306 

From bowels, excess of.. 306 

Perversion of the 307 

Exudates from blood 312 

Extrinsic convulsions 341 

Evidence of local disease 58 

Determination of blood.321 

Of congestion 321 

Of bad blood 313 

Eye 3^6 

Diagnosis by the 49 

Color under the 83 



382 



STUDY OF DIAGNOSIS. 



"Facial expression 60 

Favoring the afl'ected part... 72 

Faeces, examination of 135 

Increase of 136 

Fluid 136 

Deficient 136 

Color of 137 

Dark brown 137 

Greenish.. 137 

Clay-colored 137 

Fetor of 138 

Cadaverous 138 

Odor of... 2<>u 

Feebleness of voice 1 74 

Foetal heart, auscultation of.195 
First elements of disease... 13 

Fivesenses 36 

Fissured tongue 95 

Flexion, extension 73 

Fluid, dullness from 182 

Forcible cough 147 

Form, recognition of 42 

Frequency of pulse 146 

Increased 316 

Functional activity of brain. 64 
Function, expression pro- 
vokes 68 

Full and broad tongue 95 

Fur, dirty tongue 103 

Fullness of tongue 106 

Full, systolic wave of pulse. 151 
Full pulse 151 

Gangrene 327 

Glairy, thin mucus 113 

Globular sputa 114 

Glands, intestinal 292 

Greenish yellow color 92 

Grayish or yellowish fur 107 

Gravity, specific. 119 

Greenish faeces 137 

Growths. .....281 

Hardness of pulse 151 

Hard, small pulse 151 

Halting voice 174 

Hacking, short, sharp cough. 178 
Hearing 42 



Health, color of pigmer. 71 

Hemorrhage 127 

Healthy standard of temper- 
ature 155 

Health, range of tempera- 

oure in 158 

Healthy sounds in chest 185 

Heart, auscultation of the. ...193 
Foetal, auscultation of... 195 

Heat from inflammation 325 

Hemiplegia 342 

Heart 352 

Huxle3 T , method of 22 

Imagination 30 

Irritation, atrophic 63 

Irritation 322 

Indications for quinine 154 

Inflammation and fever,tem- 

perature in 161 

Influence of sedatives 163 

Increased frequency of pulse3 T 3 
Inter-wave current-pulse.... 151 

Inflammation 62, 323 

Symptoms of 324 

Kesolution of 324 

Pain from 325 

Heat from 325 

Swelling from 325 

Eedness from 326 

Wrong of function from3 26 
Danger to the life from. 326 

Innervation 330 

From the brain 330 

Insanity 333 

Intrinsic convulsions 340 

Innervation, sympathetic. ...343 

Intestine, small 353 

Large 353 

Intestinal digestion 272 

Glands 292 

Irregular temperature 169 

Distribution of blood... .3 18 
Irritation, spinal 344 

Kidneys, condition of... 303, 354 

Knowledge, source of 17 

Senses the source of 32 



INDEX. 



383 



Law of expression 57 

Larynx 352 

Large intestine . 353 

Lesions of nutrition 314 

Life, one 12 

Wrong 12 

Study of 13, 16, 17 

Living man, study of. 18 

Light , 40 

Lines, white around mouth... 84 

Lip, pallid upper 84 

Liver, percussion of. 183, 289,353 
Local disease, evidence of.... 58 

Diseases 66 

Color 83 

Bright red color 87 

Excess of color 91 

Disease 51 

Lungs, the 352 

Defect in excretion from297 
Lymphatic glands 353 

Man, study of the living... 18 

Mania, puerperal 332 

Method of Huxley 22 

Measurement 24 

Methods of diagnosis 28 

Mediate or direct percussion 180 

Medical stinks. 196 

Medication, restorative.. .....273 

Metamorphosis, retrograde. .279 

Mouth, expression of. 67 

White lines around the. 84 
Bluish tint around the... 85 

Salivary glands 353 

Movement, rapid 71 

Unsteady 71 

Moistening tongue 96 

Movements of tongue 107 

-Morbid sounds 186 

Moist, blowing sounds 188 

Muscles 74 

Mucous membranes, color of 77 

Muddy color of blood 82 

Mucus, thin, glairy, opaque..H3 

Dessicated 114 

Streaked with blood, 115,293 
Muscular tissue 356 



Names, prescribing at 10 

Nausea 67 

Names necessary 214 

Nipple, areola color of the... 83 

Nosology 207 

Errors from 9, 208 

Distinction & definition. 2w9 

Useless 15 

Nosological classification.. 348 

Nose 352 

Educated 196 

Examination of dis- 
charges from the 109 

Nomenclature 210 

Nutrition, lesions of 314 

Objects of the examination... 118 

Odor of the excretions 199 

Of the urine 200 

Seminal 200 

Of fasces 200 

(Esophagus ......353 

One body, one life 12 

Opaque mucus 1 13 

Ovaries 355 

Pain 56, 68, 203, 336 

Cry of ,.. 43 

From inflammation 325 

The result of two condi- 
tions 6'9 

In the abdomen 69 

Pallid upper lip 84 

Pallid and broad tongue 101 

Palpation 183 

Patient, information from. ..200 

Pancreas ....291 

Paralysis 342 

Paraplegia 343 

Percussion 179 

Direct or mediate 180 

Rules for 180 

Object of ... ...... 180 

Standard of comparison. 181 

Normal resonance 181 

Increased resonance 181 

Dullness 181 

Dullness from fluid 182 



384 



STUDY OF DIAGNOSIS. 



Percussion on other parts... 182 
Over liver and bowels... 183 

Pectoriloquy 192 

Perversion of secretion 300 

Of urine 304 

Of the excretions from 

the bowels 307 

Peritoneum 354 

Physical diagnosis 179 

Physiology applied 22 

The basis of practice 27 

Physiological standard 24 

Table 215 

Physics of auscultation 186 

Pharynx 352 

Pigment color of health... 77, 90 
Pinched & shrunken tongue. 95 

Pleura ,., 352 

Polypharmacy 11 

Position to remove pressure. 59 
Pointed, elongated tongue... 

95, 106 

Prescribing at names 10 

Prostate gland 354 

Purple dull color 81 

Purplish 82 

Color, local 88 

Pus 114 

Puerperal mania 332 

Pulse, the 144 

Analysis of 145 

Frequency of 146 

Respiratory association 147 
Relation of temperature 

to 148 

Blood waves. , 149 

Volume 149 

Sharp impulse 1 50 j 

Dull, elastic stroke 150 

Length of blood wave... 150 

Oppressed 150 

Surface of wave ...150 

Shock wave 150 

Pull, systolic wave 150 

Inter-wave current 151 

Full 151 

Hardness 151 

Small, hard 151 



Pulse, small, soft 151 

Small, vibratile 151 

Empty 151 

Remedies indicated by .=.152 
Indications for quinine..!54 

Relation to touch 155 

Relation to temperature. 160 
Increased frequency of..316 

Slowness of. 317 

Changes in the charac- 
ter of. 318 

Pyaemia 349 

Quantity of urine 119 

Quinine, indications for 154 

Rapid movement 71 

Range of temperature in 

health 158 

In disease 159 

Recognition bj r touch 21 

Of form 42 

Rest and unrest 54 

Effort for 71 

Resonance normal 181 

Increased 181 

Red, dark color 80 

Bright color, local 87 

Deep color, local 88 

Redness, erysipelatous color, 89 

Tip and edges of tongue, 101 

Red, deep tongue 102 

Reactions of saliva Ill 

Respiration, association of 

pulse 147 

Remedies indicated by pulse, 152 
Relation to touch by pulse... 155 
Registering thermometer.... 157 
Relations of pulse and tem- 
perature 148, 160 

Restorative medication 273 

Retrograde metamorphosis..279 
Recrementitious secretion. ..286 
Resolution of innammation..324 

Saliva, increased 110 

Salivary glands 353 

Scanty urine 302 



INDEX. 



385 



Scorbutus 348 

Senses, education of 32 

The source of knowledge, 32 

Acquired. 33 

Developed by use 34 

Lost by disuse , 35 

Conscious life thro' the... 36 

Five 36 

Cultivation of the 38 

Use of in diagnosis 48 

Sediment cf urine, examina- 
tion of 132 

Seminal odor 200 

Secretion 282 

Secreting cells 283 

Secretions, recrementitious. .286 

Sebaceous ,294 

Excrementitious 296 

Defectin 299 

Perversion of 300 

From the skin, excess in, 298 

Sepsis of blood 312 

Sensibility 335 

Shrunken, pinched tongue... 95 

Sharp pulse 150 

Shock wave 150 

Sharpness of voice 175 

Shrillness of voice 175 

Short, sharp hacking cough, 177 
Sick, exaggeration by the.... 29 

Sickly appearance 76 

Skin, regulating temperature 

by 166,356 

Slick tongue 103 

Slowness of pulse 317 

Smell 44 

Small tongue, full in centre, 106 

Hard pulse 151 

Soft pulse. 151 

Smell, diagnosis by 195 

Small intestines 353 

Source of knowledge 17 

Softening of the brain 63 

Sobbing respiration 175 

Sounds, healthy in chest 185 

Morbid 186 

Blowing. 187 

Blowing and moist 188 



Sounds, tremulous 189 

From cavities , 190 

Small, blowing 190 

Crepitant 191 

Adventitious 193 

Sputa, globular 114 

Cheesy 114 

Specific gravity. ........3.19 

Spasmodic cough. ........179 

Spansemia , 311 

Spinal innervation 338, 344 

Cord 351 

Spleen , 354 

Studv of diagnosis 9 

Of life 13, 16, 17 

Of the living man 18 

Of animals 50 

Objects of 52 

J Standard, physiological. 24 

I Stomach, examination of 

discharges from ,112 

j Stroke, dull, elastic of pulse.150 

! Strength of voice 173 

Of cough 177 

! Standard of comparison 181 

Stethoscope ..184 

Study of auscultation in 

English 186 

Stinks, medical 196 

Stomach 353 

Surgeon, education of 17 

Surface, color of 75 

Of pulse wave 150 

Suppuration 327 

Swelling from inflammation, 325 
Sympathetic, condition of... 65 
Symptoms of convulsions... 74 

Systolic wave, pulse full 151 

Symptoms of inflammation. .323 
Sympathetic innervation.. ..343 

Taste 46 

Tallow-like color of pigment, 92 
Table of urinary deposits. ...134 

Physiological 215 

Of Dr. Williams 216 

Temperature. 155 

Healthy standard of.,. .155 



386 



STUDY OF DIAGNOSIS. 



Temperature, range of in 

health 158 

Kange of in disease. 159 

Relation to pulse .1G0 

In chronic diseases 1G0 

In fever and inflamma- 
tion 161 

Treatment for 162 

Influence of sedatives on 163 
Relation to functional 

disease 164 

A cause of disease 165 

Regulation of the skin... 166 

Baths in 167 

Waste of tissue 167 

Depression of 168 

Irregular 169 

Changes of kind 170 

i'eHrs .295 

Testes 353 

Thermometer, bod}- 156 

Registering 157 

Use of 158 

Tissues, condition of 278 

Muscular 356 

l'ongue, examination of the, 93 

Indications from 94 

Change of form 94 

Elongated and pointed.. 95 

Full and broad 95 

Pinched, shrunken 95 

Fissured 95 

Dryness, moisture 96 

Coatings of 97 

Coatings, whiteness of... 98 
Coatings, transparent... 98 

Heavily loaded 99 

Coatings yellow 100 

Redness of tip and edgeslOl 
Represents the blood.. .101 

Broad and pallid 101 

Deep red 102 

Violet colored- 103 

Thick and large 103 

Leaden 103 

Slick 103 

Dirty fur 103 

Brown and black fur... 104 



'Tongue, dark coatings 104 

Dryness of 105 

Contraction of 106 

Fullness of 106 

Elongated and pointed..] 06 
Small, full in centre...... 106 

Grayish or yellowish fur, 107 
Movements of 107 

Touch, the 21. 39 

Diagnosis by the 139 

In obstetrics 141 

Relation of pulse to 155 

Tonsils 353 

| Transparency and clearness 

of color 78 

Transparent color of pigment, 90 

Track respiratory, examina- 
tion of discharges from..H3 

Tremulous sounds on auscul- 
tation 189 

Typhoid color 80 

Unrest 54 

Unyielding color ." 81 

Uncertainty of information 
from patient and nurse.. 201 

Upper lip pallid 84 

Urine, examination of the... 

116,301 

Deposits from 129 

Clinical examination of,130 
Without visible deposit, 130 
Examination of the sed- 
iment 132 

Odor of 200 

Scanty 302 

Urinary deposits, table of... 134 
Wrongs, symptoms of... 302 

j Urethra 355 

iUTOscopy 117 

: Useless nosology 15 

i Use of the senses in diagno- 
sis 48 

Uterus 355 



"Variations of color in disease, 42 

Vagina and vulva 355 

Venous obstruction 79 



INDEX. 



387 



Veins 355 

Blueness of 86 

Violet color 82 

Colored tongue 103 

Vibratile pulse 151 

Vomiting 112 

Vomit, black 113 

Volume of pulse... 149 

Volition, will 334 

Voice, expression of the 172 

Expresses disease 173 

Strength of 173 

Feebleness of 174 

Of nervous irritation. ...174 

Halting 174 

Oppressed... 174 

Sharpness of 175 

Encephalique 175 

Shrillness of 175 

Sobbing respiration 175 

Want of color 93 



Wave of blood 149 

Blood, length of 150 

Surface of 150 

Shock 150 

Full, systolic 151 

Intercurrent 151 

Waste of tissue 167 

White lines around niouh .. 84 

Whiteness of tongue 98 

Will, volition 334 

Williams Dr., table of 216 

Wrong life 12 

Cardiac, color from 89 

Wnmgs of function from in- 
flammation 326 

Yellow, greenish color of 

pigment 92 

Bright color of pigment 92 
Coatings of tongue 100 

Yellowish fur on tongue 1,07 



ECLECTIC MEDICAL BOOKS. 



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